Fludarabine And Cyclophosphamide Research Articles

Updated Results of the Phase I BALLI-01 Trial of UCART22 Process 2 (P2), an Anti-CD22 Allogeneic CAR-T Cell Product Manufactured By Cellectis Biologics, in Patients with Relapsed or Refractory (R/R) CD22+ B-Cell Acute Lymphoblastic Leukemia (B-ALL)

Introduction: UCART22 is a genetically modified allogeneic T-cell product manufactured from healthy donor cells. Donor-derived T-cells are transduced using a lentiviral vector to express the anti-CD22 chimeric antigen receptor (CAR) and are further modified using Cellectis' TALEN ® technology to disrupt the T-cell receptor alpha constant ( TRAC) and CD52 genes to minimize risk of graft-vs-host disease (GvHD) and allow use of an anti-CD52 antibody for lymphodepletion (LD). Preliminary results from patients treated with UCART22 manufactured by a CMO (Process 1 (P1)) showed that UCART22 was well-tolerated and meaningful responses were achieved at the highest dose level (DL 3; 5 x 10 6 cells/kg). The fludarabine, cyclophosphamide, and alemtuzumab (FCA) LD regimen was also shown to extend host lymphocyte suppression and improve UCART22 expansion versus fludarabine and cyclophosphamide (FC) alone (Boissel N, et al. EHA 2023). We now report updated results from the BALLI-01 study that includes the first patients treated with UCART22 Process 2 (P2) manufactured by Cellectis Biologics. Methods: The primary endpoints are safety, tolerability, and determining the MTD/RP2D of UCART22. Additional endpoints are anti-leukemic activity and expansion of UCART22. Eligibility criteria include age 15‒70y, B-ALL blast CD22 expression ≥ 70%, and ≥ 2 prior treatment regimens. After FCA (F 30 mg/m 2 × 3d, C 0.5g/m 2 × 3d, A 20 mg/d × 3d) LD regimen, pts received a single infusion of UCART22-P2. In vitro comparability assays suggested that UCART22 P2 was more potent than UCART22 P1, so dose escalation with UCART22 P2 started at DL2 (1 x 10 6 cells/kg) compared to the highest studied dose DL3 (5 x 10 6 cells/kg) with UCART22 P1. Results: As of 01 July 2023, 3 pts were enrolled into the first UCART22 P2 cohort at DL2. Pt 1 is a 17yo female with B-ALL with a hypodiploid karyotype and a germline TP53 mutation whose disease had previously failed to respond to multiagent chemotherapy, blinatumomab (blina), inotuzumab (ino), venetoclax (ven), allogeneic hematopoietic stem cell transplantation (HSCT), and autologous CD19 CAR T-cell therapy (CAR19) x2. Pt 2 is a 68yo female with Ph-negative B-ALL who relapsed with CD19-low disease after multiagent chemotherapy, ino, and blina. Pt 3 is a 27yo male with B-ALL with an ABL2 fusion who had failed multiagent chemotherapy, ino, blina, TKIs, and an experimental autologous CAR19. UCART22 P2 administered after the FCA LD regimen was well tolerated. No DLTs or ICANS were observed. Cytokine release syndrome (CRS) occurred in 2/3 (67%) pts, with one G1 that resolved without treatment and one G2 that resolved after tocilizumab x1. There was one G5 sepsis SAE at D40 considered related to UCART22 P2 and FCA LD in Pt 1. Responses were assessed beginning on D28. Up to FC/FCA-DL3 with 18 pts treated with UCART22 P1, 1 CR, 4 CRi, and 2 morphologic leukemia-free states (MLFS) were observed, with 3 responses occurring out of 6 (50%) patients treated with FCA-DL3 (previously reported, EHA 2023). For UCART22 P2, FCA-DL2, 2/3 pts (67%) responded: Pt 2 achieved an MRD neg CR lasting over 84 days after UCART22 infusion; Pt 1 achieved an MRD negative MLFS up to D40. Pt 3 was refractory to treatment, however this pt received bridging therapy with dasatinib for his ABL2 fusion, and on Day -1, only 47% of the leukemic cells expressed CD22 (down from 88% at screening). UCART22 P2 expansion was observed by flow cytometry in peripheral blood with peak of 79 cells/μl in Pt 1 and 225 cells/μl in Pt 2, both at D11, with predominantly CD8 cells expanding. Inflammatory markers such as ferritin, IFN-γ, TNF-α and IL-6 levels increased more than 3-fold, correlating with UCART22 P2 expansion and CRS. Summary : In vitro comparability studies indicated that UCART22 P2 was more potent than UCART22 P1, and this was suggested clinically, as there was a 67% response rate at DL2 with UCART22 P2 compared to 50% at DL3 with UCART22 P1. Use of UCART22 P2 did not lead to any grade ≥3 CRS, and no DLTs or ICANS was observed. UCART22 P2 expansion was seen in the two responders, which closely correlated with CRS and changes in inflammatory markers. These data support the safety and preliminary efficacy of UCART22 P2 in this poor-risk R/R B-ALL population. The study continues to enroll pts treated with UCART22 P2 at dose level 2i (2.5 x 10 6 cells/kg), and updated data will be presented.

Real-World Response Rates across Lines of Therapy Among Patients with Relapsed/Refractory Follicular Lymphoma

Background: Follicular lymphoma (FL) is the most common indolent subtype of non-Hodgkin lymphoma. Despite the generally indolent nature of the condition, there are subgroups of FL patients who may not have an indolent experience, with their disease not responding to multiple lines of therapy. Thus, optimization of novel therapy could improve patient outcomes. This analysis examined treatment patterns, overall response rates (ORR), and complete response (CR) rates by line of therapy (LOT) in relapsed/refractory (R/R) FL in third-line or later (3L+) therapy. Methods: This retrospective observational study was conducted using the COTA database, comprising electronic health records (EHR) from academic (50%) and community (50%) practices in the US. Adults with a confirmed diagnosis of FL, with 3L+ therapy initiation in 2010 or later, at least 3 months of follow-up, and any response assessment after 3L initiation were included. LOTs eligible for inclusion met the following conditions: treatment with an anti-CD20, alkylating agent, or lenalidomide, and no investigational drug in the selected LOT. In addition, patients with only 3L had that line selected; patients with more than 1 eligible LOT had only 1 LOT randomly selected for the analysis. Outcomes were assessed by FL International Prognostic Index (FLIPI), double refractory (DR) status, and type of therapy. DR status was defined as being refractory (disease progression or initiation of a new LOT in <6 months) to an anti-CD20 monoclonal antibody therapy and an alkylating agent. Chemoimmunotherapy (CIT) regimens included obinutuzumab/rituximab + bendamustine (OB/BR), rituximab/obinutuzumab+cyclophosphamide, doxorubicin, vincristine, and prednisolone (R/O+CHOP), R/O+CVP, R/O+other alkylating agent, and R/O+fludarabine and cyclophosphamide (FC). Novel therapies included lenalidomide + rituximab (R 2), phosphatidylinositol-3-kinase (PI3K) inhibitors, and chimeric antigen receptor T-cell therapy (CAR T). The proportion of patients with CR (as retrieved from clinician documentation in EHR) as the physician-reported response within each LOT was calculated. ORR was calculated as the proportion of patients with a CR or PR. Response rates were reported by LOT (3L, 4L, 5L+) and stratified by patient age (<65 vs ≥65 years), FLIPI score (low/intermediate vs high), and DR (not DR vs DR). Results: Overall, 240 patients with R/R 3L+ FL were included: 3L (n=140), 4L (n=55), and 5L+ (n=45). At 3L initiation, median age was 66 years and most patients were male (58.8%), White (89.6%), and had FL grade 1/2 (72.5%); 47.9% of patients were DR, 22.9% had novel therapy use, and 51.3% had CIT use. A total of 152 patients had FLIPI scores available, 38.2% of whom had high-risk scores at 3L initiation. Among all R/R 3L+ FL patients, ORR was 67.9%, with CR in 30.4% ( Figure 1). Response rates decreased across LOTs for both ORR (3L: 72.9%; 4L: 65.5%; 5L+: 55.6%) and CR (3L: 35.0%; 4L: 30.9%; 5L+: 15.6%) ( Figure 2). ORR was higher among all R/R 3L+ FL patients <65 years vs ≥65 years (75.5% vs 62.3%), as was CR rate (36.3% vs 26.1%). Among the subset of R/R 3L+ FL patients with a FLIPI score, those with low/intermediate risk vs high risk had a greater ORR (78.7% vs 58.6%) and CR rate (36.2% vs 20.7%). ORR was also higher for R/R 3L+ patients without DR status vs with DR status (73.0% vs 63.2%), as was CR rate (37.4% vs 24.0%). Patients receiving novel therapy 3L+ had an ORR of 70.9% and a CR rate of 27.3%. Among R/R 3L+ FL patients, more LOTs of CIT were associated with decreased response rates; patients with CIT in 1 LOT vs CIT in >2 LOTs had greater ORR (76.4% vs 69.2%) and CR rate (37.4% vs 26.9%). Conclusions: This analysis provides granular details on patients with R/R FL with poor prognosis. Patients with FL who progress to later LOTs have worsening response rates. This analysis included more patients with later LOTs than previously published reports, providing additional insight into response rates as treatment progresses. Lower response rates were observed among patients ≥65 years, those with a high-risk FLIPI score, and those with DR status. The high utilization of CIT in later LOTs, despite suboptimal response rates, especially among subgroups of patients with FL who may not have indolent experience of the disease, underlines the need for efficacious alternative therapies in patients with R/R 3L+ FL.

Emerging Therapies in CLL in the Era of Precision Medicine.

Over the past decade, the treatment landscape of CLL has vastly changed from the conventional FC (fludarabine and cyclophosphamide) and FCR (FC with rituximab) chemotherapies to targeted therapies, including inhibitors of Bruton tyrosine kinase (BTK) and phosphatidylinositol 3-kinase (PI3K) as well as inhibitors of BCL2. These treatment options dramatically improved clinical outcomes; however, not all patients respond well to these therapies, especially high-risk patients. Clinical trials of immune checkpoint inhibitors (PD-1, CTLA4) and chimeric antigen receptor T (CAR T) or NK (CAR NK) cell treatment have shown some efficacy; still, long-term outcomes and safety issues have yet to be determined. CLL remains an incurable disease. Thus, there are unmet needs to discover new molecular pathways with targeted or combination therapies to cure the disease. Large-scale genome-wide whole-exome and whole-genome sequencing studies have discovered genetic alterations associated with disease progression, refined the prognostic markers in CLL, identified mutations underlying drug resistance, and pointed out critical targets to treat the disease. More recently, transcriptome and proteome landscape characterization further stratified the disease and revealed novel therapeutic targets in CLL. In this review, we briefly summarize the past and present available single or combination therapies, focusing on potential emerging therapies to address the unmet clinical needs in CLL.

Ameli-01: A Phase I Trial of UCART123v1.2, an Anti-CD123 Allogeneic CAR-T Cell Product, in Adult Patients with Relapsed or Refractory (R/R) CD123+ Acute Myeloid Leukemia (AML)

Introduction: UCART123v1.2 is a genetically modified allogeneic T-cell product manufactured from healthy donor cells. Donor-derived T-cells are transduced using a lentiviral vector to express the anti-CD123 chimeric antigen receptor and are further modified using Cellectis' TALEN® technology to disrupt the T-cell receptor alpha constant (TRAC) and CD52 genes to minimize risk of graft-vs-host disease (GvHD) and allow use of anti-CD52-directed therapy as part of lymphodepletion (LD). AMELI-01 (NCT04106076) is a phase 1, open-label, dose-escalation trial evaluating the safety, tolerability, expansion, and persistence of UCART123v1.2 given at escalating dose levels after LD with either fludarabine and cyclophosphamide (FC) or FC with alemtuzumab (FCA) in patients (pts) with R/R CD123+ AML. Alemtuzumab was added to the LD regimen to sustain host T- and NK-cell depletion and to promote UCART123v1.2-cell expansion and persistence. Methods: Key eligibility criteria include pts 18-65 yrs, adequate organ function, ECOG PS ≤ 1, and blasts positive for CD123 by flow cytometry. Pts must have received ≥2 cycles of chemotherapy (one with standard dose cytarabine), ≥ 1 cycle of a high/intermediate dose cytarabine containing regimen, ≥ 2 cycles of an HMA combination regimen, or prior allogeneic HSCT. After LD with FC or FCA, pts received UCART123v1.2 at one of the following dose levels: 2.5x105 cells/kg (DL1); 6.25x105 cells/kg (DL2); 1.5x106 cells/kg (DL2i); or 3.03x106 cells/kg (DL3). The primary endpoint is the safety, tolerability, and MTD/RP2D of UCART123v1.2. DLTs are assessed over a 28d observation period after UCART123v1.2 infusion. Additional endpoints include investigator assessed anti-leukemic activity per 2017 ELN criteria, and expansion, trafficking, and persistence of UCART123v1.2 (assessed in peripheral blood [PB] and bone marrow [BM] by flow cytometry and vector copy number [VCN]). Measurable residual disease (MRD) was analyzed by local multiparameter flow cytometry with a sensitivity of 0.02%. Results: As of July 1, 2022, 16 pts received LD and UCART123v1.2; 8 pts received UCART123v1.2 after FC (DL1 [n=2]; DL2 [n=3]; DL2i [n=2]; DL3 [n=1]), and 8 pts received UCART123v1.2 after FCA (DL2). Pts were high risk and heavily pretreated with disease characteristics outlined in Table 1. Median baseline BM and PB % blasts was 37% (0-88%) and 19% (0-79%), and median baseline CD123 positivity by central flow cytometry in the FC and FCA arms was 82% (17-98%) and 84% (25-97%), respectively. Four pts experienced DLTs: 3 pts in FC arm (G4 CRS [1pt in DL2i and 1pt in DL3] and G3 ICANS [1pt in DL2i]); and 1 pt in FCA arm (G5 CRS in DL2). Cytokine release syndrome (CRS) occurred in 15/16 pts (FC arm [n=7]; FCA arm [n=8]), of which 3 pts experienced ≥ G3 CRS which were classified as DLTs as noted above (FC arm G4 [n=2]; FCA arm G5 [n=1]). Responses were assessed beginning on D28. Evidence of UCART123v1.2 activity was observed in 4/16 pts with best overall responses as follows: FC arm (DL2: 1 SD; DL2i: 1 MLFS); FCA arm (DL2: 1 SD and 1 MRD-negative CR). The pt in the DL2 FCA arm with SD achieved greater than 90% BM blast reduction (60% to 5%) at D28. The pt with CR, who had failed 5 prior lines of therapy including HSCT and had baseline G4 cytopenias, had CRi at D28 with full count recovery at D56 and remains in an MRD-negative CR beyond the 8-month f/u visit. Adequate lymphodepletion was not achieved in the FC arm, as host lymphocyte recovery was observed in 7/8 pts prior to D28, and only 3/8 pts had UCART123v1.2 expansion (Cmax ranged from 3,757 to 27,828 copies/μg DNA). In contrast, FCA LD resulted in robust lymphodepletion for greater than 28 days in all pts, and 6/8 demonstrated UCART123v1.2 expansion, with Cmax ranging from 13,177 to 330,530 copies/μg DNA, an almost 9-fold increase compared with FC LD. An increase in inflammatory markers, notably serum ferritin, and serum cytokines (including IL-2, IL-6, IL-10, IL-15, IFN-γ, and TNF-α) in the FCA arm correlated with both UCART123v1.2 expansion and CRS. Conclusions: Adding alemtuzumab to the FC regimen was associated with improved LD and significantly higher UCART123v1.2 cell expansion and persistence, which correlated with improved activity and safety, including one pt in the DL2 FCA arm who achieved a durable MRD-negative CR. Overall, these data support the safety and activity of UCART123v1.2 after FCA LD in pts with CD123+ R/R AML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Decitabine in Combination with Fludarabine and Cyclophosphamide As Lymphodepletion Regimen Followed By CD19/CD22 Bispecific Targeted CAR-T Therapy Significantly Improves Survival in Relapsed/Refractory B-ALL Patients: A Pilot Study

Background: CD19/CD22 bispecific targeted chimeric antigen receptor T cell (CAR-T) therapy has achieved impressive progress in patients with relapsed/refractory B cell acute lymphoblastic leukemia (R/R B-ALL), with high rates of complete remission (CR). However, T cell exhaustion caused by de novo DNA methylation restricts the capacity of CAR-T. Decitabine (DAC), a DNA methyltransferase inhibitor, has been demonstrated to reverse exhaustion-associated DNA-methylation programs, promote the rejuvenation of CAR-T cells and enhance anti-leukemic effect of CAR-T cells in vitro. To date, there are limited reports about the use of DAC as a part of lymphodepletion therapy before CAR-T cell therapy. Here, we report efficacy and safety of DAC in combination with fludarabine and cyclophosphamide (FC) regimen followed by CD19/CD22 CAR-T cell therapy for patients with R/R B-ALL.Method:We conducted a phase 1/2 clinical trial to investigate the efficacy and safety of CD19/CD22 CAR-T in the treatment of R/R B-ALL (NCT03614858). Fourteen patients were treated with DAC (total dose 100mg/m 2 in 3 days) followed by FC regimen (fludarabine 30mg/m 2 × 3d and cyclophosphamide 300mg/m 2 × 3d) (DAC group), while twelve patients received FC regimen prior to CAR-T cell infusion (CON group). A total of 1 or 2 × 10 7 CAR-T cells/kg were infused at dose escalation.Results: Baseline characteristics of patients in both groups had no significant differences except previous hematopoietic stem cell transplantation (HSCT). There were more patients with relapse after HSCT in DAC group (42.9% versus 0%, P=0.017). All patients did not achieve remission before lymphodepletion. The day 28 CR rates were 100% in DAC group and 91.7% in CON group. Furthermore, minimal residual disease (MRD) negative CR rates were 71.4% and 58.3%, respectively (P = 0.683). There was no significant difference in the proportion of nontransplant patients after CAR-T treatment between two groups. Among the nontransplant patients after CAR-T infusion in DAC group, 16.7% (1/6) of patients relapsed at 4 months. However, among 4 nontransplant patients in CON group, 1 patient achieved NR after CAR-T therapy and 3 patients relapsed at 1.5, 5, and 10 months. There were significant differences in overall survival (OS) and leukemia-free survival (LFS) between two groups: 3-year OS, 88.9% (DAC) versus 33.3% (CON), P = 0.01 and 3-year LFS, 92.3% (DAC) versus 21.8% (CON), P = 0.002. Multivariable analysis showed that addition of DAC to the lymphodepletion regimen was associated with better OS (hazard ratio [HR] 0.107, [95% CI, 0.013-0.875], P = 0.037) and LFS (HR 0.081, [95% CI, 0.01-0.65], P = 0.018). Cytokine release syndrome was observed in all patients.Conclusion: In summary, DAC in combination with FC regimen followed by CD19CD22 CAR-T cells was feasible and well tolerated. Our study demonstrated DAC combined with FC was an independent prognostic factor correlated with better survival in relapsed/refractory B-ALL patients. DisclosuresNo relevant conflicts of interest to declare.

Preliminary Results from the Flu/Cy/Alemtuzumab Arm of the Phase I BALLI-01 Trial of UCART22, an Anti-CD22 Allogeneic CAR-T Cell Product, in Adult Patients with Relapsed or Refractory (R/R) CD22+ B-Cell Acute Lymphoblastic Leukemia (B-ALL)

Preliminary Results from the Flu/Cy/Alemtuzumab Arm of the Phase I BALLI-01 Trial of UCART22, an Anti-CD22 Allogeneic CAR-T Cell Product, in Adult Patients with Relapsed or Refractory (R/R) CD22+ B-Cell Acute Lymphoblastic Leukemia (B-ALL)

Mode of Progression after First Line Treatment Correlates with Outcome of Chronic Lymphocytic Leukemia (CLL)

Mode of Progression after First Line Treatment Correlates with Outcome of Chronic Lymphocytic Leukemia (CLL)

Patients with Chronic Lymphocytic Leukemia Belonging to the B-Cell Receptor Stereotypy Subset #2 Have Long Progression Free Survival after Chemo- or Chemoimmunotherapy in the HOVON68 Trial

Abstract Introduction: About one third of all patients with Chronic Lymphocytic Leukemia (CLL) have quasi-identical, so-called stereotyped B-cell receptors (BCR) that can be divided into subsets (Agathangelidis et al. Blood 2012). At present, 19 major subsets have been described that account for approximately 12% of all patients with CLL. Of these, subsets #1 and #2 are associated with a poor prognosis (Baliakas et al. Lancet Hematology 2014). The HOVON68 trial compared fludarabine and cyclophosphamide (FC) chemotherapy to chemo-immunotherapy with low-dose alemtuzumab (FCA) as a first line treatment in selected high risk patients defined as either harboring 17p deletion, 11q deletion, trisomy 12, having unmutated mmunoglobulin heavy variable genes (IGHV) and/or VH3-21. The study showed a benefit of adding low-dose alemtuzumab to FC (Geisler et al. Blood 2014). Here, we studied the impact of BCR stereotypy subsets on the primary outcome progression free survival (PFS) and overall survival (OS). Methods: Sequences from IGHV mutational analyses were collected from participating centers in Sweden, Norway, Finland, Denmark, and the Netherlands. Subsets were assigned based on the ARResT/AssignSubsets software (Bystry et al. Bioinformatics 2015). Analysis for recurrent mutations were performed by next generation sequencing by a 454 based platform (Roche Diagnostics Corporation, Indianapolis, USA). All other clinical data were extracted from the HOVON database as of November 2016. Kaplan-Meier curves, log-rank tests, and Cox regression models were used for survival analysis. Fisher's exact test was used for contingency table analysis. P-values Results: A total of 187 sequences were available. Of these, 176 were suitable for analysis. We found a total of 37 patients (21%) that could be assigned to one of the 19 major subsets: Subset #2 was the most frequent (n=12, 6.8%), thereafter subset #8 (n=7, 4.0%), subset #6 (n=6, 3.4%), and subset #1 (n=5, 2.8%). The median follow-up time for patients still alive was 78.6 months. By November 2016, 148 patients (84%) had had an event (no response to treatment, progression, or death) and 77 patients (44%) had died. Compared to patients belonging to other major subsets, patients with subset #2 did not differ significantly as to: age group above 65 years, gender, treatment arm, cytogenetic aberrations by FISH, WHO performance status, beta2microglobulin level>3.5 mg/L, or in complete response rates, However, patients with subset #2 had more advanced disease (Binet stage C 83% vs. 52%, p=0.04) and as expected less often unmutated IGHV genes (67% vs. 100%, p=0.01). Nineteen of 37 patients (51%) was analyzed for recurrent mutations: Only SF3B1 mutations was found in patients with subset #2, and the frequency was slightly higher compared to other major subsets (57% vs. 17%, p=0.13), in whom also KRAS2 (17%) and BRAF15 (8%) mutations was found. Unexpectedly, patients with subset #2 had a longer PFS compared to patients with other major subsets (median PFS #2: 51.2 months vs. other major #: 31.1 months, p=0.002, Figure), or compared to patients with usage of the same IGHV gene (e.g. median PFS for 7 patients with VH3-21/non #2: 15.4 months, p Discussion and conclusions: As expected, stereotypy was found more frequently in the HOVON68 trial that selected for high risk patients as compared to patients from large multi-institutional studies (Stamatopoulos at al. Leukemia 2017). Surprisingly, patients belonging to subset #2 had a better PFS after chemo-(immuno) therapy compared to other major subsets, albeit the numbers are small. Our data suggest that, chemo-(immuno) therapy may still have a place for patients otherwise assessed as ‘high risk’ such as patients with B-cell receptor stereotypy subset #2. Thus, selection of patients for trials as well as the exact treatment regimen may have major impact on the significance of biomarkers. Download : Download high-res image (115KB) Download : Download full-size image Figure . Disclosures Vojdeman: Roche: Other: Travel support in 2015; Gilead: Other: Travel support. Kimby: Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Membership on an entity's Board of Directors or advisory committees; Gilead: Honoraria; Celgene: Research Funding; Pfizer: Research Funding. Van Oers: Roche: Consultancy; ISA therapeutics: Consultancy; Novartis: Consultancy; Immunicum: Consultancy. Kater: Celgene: Consultancy, Research Funding; Johnson & Johnson: Research Funding; Abbvie: Research Funding. Niemann: Roche: Consultancy, Other: Travel grant; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel grant; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel grant; Novo Nordisk Foundation: Research Funding; The Danish Cancer Society: Research Funding; Novartis: Other: Travel grant; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Travel grant, Research Funding.

Safety of Obinutuzumab Alone or Combined with Chemotherapy in Previously Untreated (Fit or Unfit) or Relapsed/Refractory Chronic Lymphocytic Leukemia (CLL) Patients: Results from the Primary Analysis of the Phase 3b GREEN Study

Safety of Obinutuzumab Alone or Combined with Chemotherapy in Previously Untreated (Fit or Unfit) or Relapsed/Refractory Chronic Lymphocytic Leukemia (CLL) Patients: Results from the Primary Analysis of the Phase 3b GREEN Study

CD38-Directed CAR-T Cell Therapy: A Novel Immunotherapy Strategy for Relapsed Acute Myeloid Leukemia after Allogeneic Hematopoietic Stem Cell Transplantation

There are few effective therapies for relapsed acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which has a poor prognosis. Although CD19-targeted chimeric antigen receptor T cell (CAR-T-19) therapy has achieved remarkable success for B-cell malignancies, few successful CAR-T cell therapies in AML have been reported. In this prospective study, we explored the therapeutic effect and clinical safety of the application of CAR-T-38 in 6 AML patients with relapsed post allo-HSCT and CD38 expression. The decitabine (DAC) + HAAG regimen was used to reduce tumor burden, followed by the fludarabine and cyclophosphamide (FC) regimen for lymphodepletion chemotherapy before CAR-T cell infusion. In total, 8.05 (6.1-10) x 106/kg CAR-T-38 were infused by dose escalation over a 3- to 4-day period. At 1, 2 and 4 weeks after CAR-T infusion, two (33.3%), four (66.7%) and four (66.7%) of six patients achieved complete remission (CR) or CR with incomplete count recovery (CRi), respectively. Five of six (83.3%) patients experienced mild (grade I-II) cytokine release syndrome (CRS), and only one patient presented grade III hepatotoxicity. No neurological toxicities were observed, but all six patients had grade III/IV hematological toxicities. The 6-month overall survival (OS) and leukemia-free survival (LFS) rates were 50% and 50%, respectively, and the median OS and LFS were 12.3 and 10.3 months, respectively. The cumulative relapse rates at 3 and 6 months were 25% and 50%, respectively. Multiparameter flow cytometry (FCM) showed that the percentage of CD38-positive blasts remarkably decreased at day 7 and remained at low levels on day 28 after CAR-T cell infusion, but CD38-positive monocytes and lymphocytes were not depleted. This study is the first to indicate that CAR-T-38 therapy is a promising effective and safe approach for patients with relapsed AML after allo-HSCT. (NCT04351022) Disclosures No relevant conflicts of interest to declare.

Ameli-01: Phase I, Open Label Dose-Escalation and Dose-Expansion Study to Evaluate the Safety, Expansion, Persistence and Clinical Activity of UCART123 (allogeneic engineered T-cells expressing anti-CD123 chimeric antigen receptor), Administered in Patients with Relapsed/Refractory Acute Myeloid Leukemia

Ameli-01: Phase I, Open Label Dose-Escalation and Dose-Expansion Study to Evaluate the Safety, Expansion, Persistence and Clinical Activity of UCART123 (allogeneic engineered T-cells expressing anti-CD123 chimeric antigen receptor), Administered in Patients with Relapsed/Refractory Acute Myeloid Leukemia

Lymphodepletion chemotherapy revitalizes chimeric antigen receptor T cells contributing to regression of relapsed B-cell lymphoma

Introduction:Chimeric antigen receptor T cells (CAR-T) targeting CD19 have shown great potential for treatment of B-cell malignancies. For those patients who can not achieve complete remission (CR) or suffer from relapse after CAR-T therapy, further therapeutic strategies still remain elusive. Whether existing CAR-T cells can revitalize in vivo and eradicate tumor cells is still unknown.Patient concerns:We report a case of diffused large B-cell lymphoma patient who had achieved CR after CD19 targeted CAR-T therapy but relapsed after 5 months.Diagnosis:Five months after CAR-T cell infusion, the patient was confirmed a relapse by follow-up PET/CT scan and a mass biopsy. Flow cytometry showed a dramatically decreased percentage of CAR-T cells in peripheral blood (PB).Interventions:A second anti-CD19 CAR-T therapy was planned with deliberation. Firstly, the patient received lymphodepletion chemotherapy with fludarabine (25 mg/m2, d1–d3) and cyclophosphamide (500 mg/m2 d2–d3).Outcomes:After fludarabine and cyclophosphamide (FC) lymphodepletion chemotherapy, pre-existing CAR-T cells were revitalized and the patient developed grade 2 cytokine release syndrome (CRS) contributing to the regression of relapsed B-cell lymphoma.Conclusions:This case suggested that FC chemotherapy could revitalize CAR-T cells contributing to the regression of relapsed B-cell lymphoma. Nevertheless, further researches are required in the future as this report described only a single case.

Treatment outcome and prognostic factors of Korean patients with chronic lymphocytic leukemia: a multicenter retrospective study.

Background/AimsCompared with Western countries, chronic lymphocytic leukemia (CLL) rarely occurs in Asia and has different clinical characteristics. Thus, we aimed to evaluate the clinical characteristics, treatment outcomes, and prognostic significance of Korean patients with CLL.MethodsWe retrospectively analyzed 90 patients with CLL who had received chemotherapy at 6 centers in Korea between 2000 and 2012.ResultsCompared with Western patients with CLL, Korean patients with CLL express lambda (42.0%) and atypical markers such as CD22 and FMC7 (76.7% and 40.0%, respectively) more frequently. First-line chemotherapy regimens included chlorambucil (n = 43), fludarabine and cyclophosphamide (FC) (n = 20), fludarabine (n = 13), rituximab-FC (n = 4). The remaining patients were treated with other various regimens (n = 10). The 5-year overall survival (OS) and progression-free survival (PFS) rates were 79.3% and 28.1%, respectively. Multivariate analyses showed that hyperleukocytosis (≥ 100 × 103/μL), extranodal involvement, and the Binet C stage were significant negative prognostic factors for OS (hazard ratio [HR] 4.75, p = 0.039; HR 21.6, p = 0.002; and HR 4.35, p = 0.034, respectively). Cytogenetic abnormalities including complex karyotypes (≥ 3), del(11q), and del(17) had a significantly adverse impact on both OS and PFS (p < 0.001 and p = 0.010, respectively).ConclusionsInitial hyperleukocytosis, extranodal involvement, complex karyotype, del(17) and del(11q) need to be considered in the risk stratification system for CLL.

Sensitivity of chronic lymphocytic leukemia cells to chemotherapeutic drugs ex vivo depends onexpression status of cell surface receptors.

The study was performed on malignant B cells isolated from peripheral blood of primary CLL patients. Flow cytometry, qPCR, ex vivo drug sensitivity assay, and cell viability assay were used in this study. The high CD5 expression level was linked to better bendamustine (BEN) and cyclophosphamide (CP) CLL B cells response in contrast to B cells with low CD5 expression. Sensitivity of CLL B cells to CP also could be predicted by high level of CD20 expression. Expression of CD38 and high levels of CD37 and CD40 showed CLL B cells resistance to BEN ex vivo. CLL B cells sensitivity to analyzed chemotherapeutic drugs was not dependent on CD22 expression status. The CD180 expression was detected in CLL B cells which were more susceptible to fludarabine and cyclophosphamide (FC) combinatory action. CLL B cells that coexpressed CD150 and CD180 on the cell surface were characterized by significantly decreased cell viability under fludarabine (FLU) exposure alone or FC in comparison with CD150-CD180- B cells. Cell surface expression level of CD150 was not associated with CLL B cells chemosensitivity. However, high mRNA expression level of mCD150 isoform in CLL B cells was linked to their FLU sensitivity and CP resistance, while high nCD150 mRNA expression level showed resistance to FLU. Simultaneous CD150 and CD180 ligation increased FLU resistance, but BEN susceptibility of CLL B cells. CD150 and CD180 alone or in combination are involved in upregulation of CD20 cell surface expression. Expression status of the CD5, CD20, CD37, CD38, CD40, CD150, and CD180 cell surface receptors could be used in prediction CLL B cells sensitivity to FLU, CP, BEN and FC ex vivo. Moreover, CD150 and CD180 receptors are involved in regulation of CLL B cells susceptibility to FLU and BEN. The CD150 and CD180 are positive regulators of CD20 expression that could make CD150+CD180+ CLL B cells more responsive to CD20-based immunotherapy.

Up to half of patients diagnosed with chronic lymphocytic leukemia in México may not require treatment

ABSTRACT Introduction: Although therapeutic choices for patients with chronic lymphocytic leukemia (CLL) were once limited, treatment of this disease has vastly improved in the last decades. Patients and methods: Consecutive CLL patients diagnosed in a single institution were analyzed. Treatment was withheld in persons with CLL Rai stage 0 or 1, until progression and in persons with stages 2–4, with a negative expression of ZAP-70 until progression. Between 1983 and 1991, patients were give chlorambucil and prednisone (CP); after 1991 fludarabine and cyclophosphamide (FC) and after 1998, rituximab and FC (FCR). Results: 98 patients with CLL were identified; 49 were followed for >3 months. 21 persons (43%) did not require treatment nor progressed; 14 received CP, 6 FC, 7 FCR and one rituximab. Median overall survival (OS) has not been reached, being above 247 months; median OS for patients given CP was 115 months, for FC above 132 months and for FCR above 136 months (p > 0.5). Conclusion: CLL seems to be less aggressive in Mexican mestizos than in Caucasians; 43% of patients do not need treatment at all.

Ibrutinib Maintenance after Chemoimmunotherapy Is Feasible and Results in Excellent Progression-Free and Overall Survival in Patients with Detectable MRD after Chemoimmunotherapy

Introduction Given the variety of highly effective therapies available for chronic lymphocytic leukemia (CLL), a tailored treatment strategy is needed. Fixed-duration chemoimmunotherapy can produce sustained and deep responses. The presence of minimal residual disease (MRD) has been studied as an independent prognostic factor for long-term survival in patients with CLL. Multiple novel agents have been recently approved for previously untreated patients, including the BTK inhibitor, ibrutinib, but its effect on MRD is still unclear. We performed a prospective clinical trial to evaluate the efficacy of maintenance therapy with ibrutinib in patients with detectable MRD after first-line chemoimmunotherapy. Patients and methods In this phase 2 clinical trial, we assessed the efficacy and safety of ibrutinib 420 mg daily as maintenance therapy, until progression or unacceptable toxicity, after achieving complete remission (CR) or partial remission (PR) with chemoimmunotherapy in previously untreated 40 patients with CLL from 9 centers in Brazil. The median age was 60 years (range: 43-85 years). Twenty-nine patients (73%) had been treated with fludarabine and cyclophosphamide (FC) ± rituximab, 10 (25%) with chlorambucil ± rituximab, and one (2%) with bendamustine + rituximab. Responses definitions were based on the 2018 iwCLL guidelines. Twenty-five patients (63%) were in CR and 15 (37%) in PR before the start of maintenance. Patients with detectable MRD within 12 months after the end of the first line chemoimmunotherapy were included. Besides, three patients with undetectable MRD were also included in order to evaluate possible effects of ibrutinib on that group. Responses were assessed monthly during the first year and every three months thereafter. MRD was assessed by 8-color flow cytometry in the bone marrow and in the peripheral blood before and after one year of maintenance therapy, and in peripheral blood every 3 months thereafter. Primary end point was progression-free survival (PFS). Results Median follow-up time was 25 months (range: 12-46 months). Among the 40 patients included, two patients withdrew consent (one just after inclusion and one after 30 days), and one patient died 7 days after ibrutinib was started due to an unrelated cause (ruptured aortic aneurysm). Thirty-seven patients were treated with ibrutinib and prospectively followed. The median PFS and overall survival (OS) were not reached. PFS and OS at 2 years were 92% and 95%, respectively. Among the 15 patients who started maintenance in PR, 8 (53%) achieved CR (3 of which had incomplete hematologic recovery), and 7 had complete nodal response, but remained in PR due to persistent lymphocytosis. Among the 22 who entered maintenance in CR, all but one remained in CR: 1 patient presented ≥ 50% increase in his baseline lymphocyte count 40 months after maintenance was started, but remains on ibrutinib with no cytopenias or clinical indication to treatment change. Among the 34 patients who had detectable MRD, 9% had at least 1-log reduction after one year and 20% after 2 years. Besides, one patient achieved undetectable MRD so far, 30 months after ibrutinib was started. All 3 patients with undetectable MRD at baseline, remained undetectable. Sustained increases from baseline values in the hemoglobin and platelet levels were observed in 30 patients (81%). Adverse events of any grade that occurred during maintenance with ibrutinib included diarrhea (23%), nausea (10%), and fatigue (8%), but only 2 patients had grade 3 diarrhea, associated with the concomitant use of metformin that resolved after discontinuation. Atrial fibrillation occurred intermittently in 3 patients during maintenance. A total of 81% of patients remain on ibrutinib. Four patients discontinued the drug: one after 8 months to perform a stem cell transplant by the decision of the treating physician, one after 10 months due to adverse events (lymphomatoid granulomatosis), and 2 after 13 months due to logistic difficulties to remain on regular follow up. Conclusions Maintenance with ibrutinib for CLL patients achieving CR or PR after chemoimmunotherapy resulted in excellent PFS and OS, and sustained improvement in hematologic variables irrespectively of achieving undetectable MRD. Efficacy of this regimen compares well to other frontline chemo-free treatments offered to patients with CLL in the United States and Europe. Disclosures No relevant conflicts of interest to declare.

Analysis of Factors Predicting Treatment Response of 254 Patients Who Received CD19-Targeted CAR-T Cell Therapy for Relapsed/Refractory (R/R) B-Cell Acute Lymphoblastic Leukemia (B-ALL)

Backgrounds Chimeric antigen receptor (CAR) T cell therapy targeting CD19 has demonstrated 80-90% complete remission (CR) rate in R/R B-ALL; however, 10% to 20% of patients have no response and the potential etiology and risk factors remain unclear. Patients and Methods From Apr. 2017 to Mar. 2019, 254 patients with R/R B-ALL received treatment at our single center with a second-generation CD 19 CAR-T from 5 companies (NCT03173417; ChiCTR-ONC-17012829; NCT02546739; ChiCTR1800016541; and NCT03671460). The targeted median infused CAR-T cell dose was 3x105/kg. For all patients, screening was undertaken for 58 types of B-ALL related gene mutations and 49 congenital immune deficiency gene mutations using next generation sequencing (NGS) method. The patient and CAR-T product characteristics were analyzed to see if any factors affected the initial CR rate. Univariate analysis comparing CR rates between subgroups were carried out using chi-squared tests. Logistic regression model was adopted for multivariate analysis. Results On D30, 90.6% (230/254) patients achieved CR, and minimal residual disease (MRD)-negative CR was 89.4% (227/254). Univariate analysis (Table 1&amp;2) showed a statistical difference in CR rate between females and males (84.54% vs. 94.27%, p=0.011). The CR rate of patients who received prior either CAR-T or blinatumomab treatment was lower than those who had not (50% vs. 91.53%, p=0.01). For the characteristic fusion genes, the CR rate in patients with MLL-AF4 was 80%, which was inferior to those with other or no fusion genes (P=0.041). For gene mutations, a lower CR rate was observed in patients with TP53 mutation compared to those with other or no mutations (72.73% vs. 92.11% vs. 94.39%, P=0.004). Presence of congenital immune deficiency gene mutations did not affect CR rate. Patients with &amp;gt;20% bone marrow (BM) blasts had a worse outcome than those with BM blasts≤20% (79.17% vs. 97.47%, p&amp;lt;0.001). There were no differences in CR between patients age 1-14 yr and &amp;gt;14 yr, patients with or without extramedullary disease (EMD), or patients receiving different chemotherapies between enrollment and CAR-T cells infusion on top of fludarabine and cyclophosphamide (FC) conditioning regimen. Cytokine release syndrome (CRS) and neurotoxicity had no effect on CR rate.There was a trend towards a lower CR rate in patients who received donor-derived CAR-T versus patient-derived CAR-T products (61.54% vs. 92.12%, p = 0.081). A lower CR rate was observed in patients who received CD28 costimulatory domain versus 4-1BB CAR-T products (77.27% vs. 91.70%, p=0.053). There was no difference in CR rate between patients infused with cell dose ≥3x105/kg vs. cell dose &amp;lt;3x105/kg and &amp;gt;2x104/kg. No CR difference was observed from different manufacturing companies. Moreover, 125/254 cases had available data for analysis on subsets of CAR-T cells including central memory T cells (Tcm), naive T cells and T memory stem cells (Tscm). Each group was divided into high- or low-level groups based on the median level. The CR rate was 92.19% vs. 88.52% in high and low Tcm groups, 92.31% vs. 88.33% in high or low naive group, and 89.80% vs.90.24% in high and low Tscm groups, respectively. No difference in CR between the groups were observed. Multivariate analysis was performed to investigate factors affecting achievement of CR (Table 3). Female group had lower odds of achieving CR after CAR-T therapy compared to male group [OR=0.232(95%CI 0.082-0.652)]. Compared to patients without TP53 mutation or only with other gene mutations, patients with TP53 mutation were more likely to have a low CR rate after CAR-T treatment [OR=4.511(95%CI 1.295-16.895)]. Patients with BM blast &amp;gt;20% had lower odds of achieving CR compared to those with BM blast ≤20% [OR=0.095 (95%CI 0.022-0.260)]. Treatment with CAR-T with CD28 as a costimulatory domain resulted lower odds of CR compared to treatment with CAR-T with 4-1BB [OR=7.141 (95%CI 1.722-29.612)]. Patients who developed severe neurotoxicity (grade 2-4) post CAR-T had higher odds of achieving CR compared to patients with grade 0-1 neurotoxicity [OR=34.796(95%CI 3.232-374.659)]. Conclusions In this analysis, we have observed that significant risk factors for not achieving CR after CD-19 CAR-T therapy include female gender, BM blasts more than 20%, a positive TP53 mutation, treatment with CD28 co-stimulatory domain vs 4-1BB CAR-T product, and mild as opposed to severe CAR-T related neurotoxicity. Disclosures No relevant conflicts of interest to declare.

Long-Term Evaluation of Efficacy and Safety of Ofatumumab Added to Fludarabine & Cyclophosphamide in Subjects with Relapsed Chronic Lymphocytic Leukemia: Final Analysis of Complement 2 Trial

Long-Term Evaluation of Efficacy and Safety of Ofatumumab Added to Fludarabine & Cyclophosphamide in Subjects with Relapsed Chronic Lymphocytic Leukemia: Final Analysis of Complement 2 Trial

Obesity Negatively Impacts Outcome in Female Patients with Chronic Lymphocytic Leukemia (CLL) Treated with Fludarabine, Cyclophosphamide and Rituximab (FCR): An Analysis of Three Phase III Studies of the German CLL Study Group (GCLLSG)

Obesity Negatively Impacts Outcome in Female Patients with Chronic Lymphocytic Leukemia (CLL) Treated with Fludarabine, Cyclophosphamide and Rituximab (FCR): An Analysis of Three Phase III Studies of the German CLL Study Group (GCLLSG)

Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up