Long-term Clinical Remissions Research Articles

Long-term genetic and clinical remissions after cessation of azacitidine treatment in patients with VEXAS syndrome.

Long-term genetic and clinical remissions after cessation of azacitidine treatment in patients with VEXAS syndrome.

Long-term outcome in patients with mantle cell lymphoma following high-dose therapy and autologous stem cell transplantation.

Long-term clinical and molecular remissions in patients with mantle cell lymphoma (MCL) after autologous stem cell transplantation (ASCT) have been evaluated in only a few studies. Sixty-five patients with MCL received ASCT (54 first-line ASCT, 10 second-line ASCT, and 1 third-line ASCT). In the case of long-term remission (≥5 years; n = 27), peripheral blood was tested for minimal residual disease (MRD) by t(11;14)- and IGH-PCR at the last follow-up. Ten-year overall survival (OS), progression-free survival (PFS), and freedom from progression (FFP) after first-line ASCT were 64%, 52%, and 59% versus after second-line ASCT 50%, 20%, and 20%, respectively. Five-year OS, PFS, and FFP for the first-line cohort were 79%, 63%, and 69%, respectively. Five-year OS, PFS, and FFP after second-line ASCT were 60%, 30%, and 30%, respectively. Treatment-related mortality (3 months after ASCT) was 1.5%. So far 26 patients developed sustained long-term clinical and molecular complete remissions of up to 19 years following ASCT in first treatment line. Sustained long-term clinical and molecular remissions are achievable following ASCT.

Ex Vivo Generation and Infusion of Anti-Minor Histocompatibility Antigen Expanded T Cells for Patients Who Relapse after Allogeneic HLA-Matched Stem Cell Transplantation

Rationale Long-term clinical remissions of hematologic malignancies after allogeneic hematopoietic stem cell transplantation (HSCT) largely rely on the graft-versus-leukemia effect (GVL). In a fully HLA-matched setting, the GVL effect is mediated primarily by T cell immune responses against host minor histocompatibility antigens (MiHAs) found on the surface of malignant cells. Upon relapse of leukemia following HSCT, donor lymphocyte infusions (DLI) have unfortunately failed to exert efficient GVL activity. This is likely due to the insufficient number of anti-MiHA T cells within DLIs and to the risk of graft-vs-host disease (GVHD) that prevents the administration of high numbers of T cells. To generate potent and selective anti-leukemia activity, we have developed a strategy for the ex vivo selection and expansion of T cells targeting MiHAs preferentially expressed on hematopoietic cells (Perreault, Leukemia 2016). Thus, these cells should display augmented GVL immune reactivity while harboring a low risk of causing GVHD. To our knowledge, this is the first clinical study targeting several different molecularly defined MiHAs and on different HLA molecules. Patients and Methods In an open-label, multi-center phase 1 clinical trial (CR-MIHA-001; NCT 03091933), patients with hematologic malignancies who relapsed after an allogeneic HLA-matched HSCT were treated with sibling donor-derived, ex vivo- expanded T cells selected and expanded for reactivity toward tissue-restricted recipient MiHAs (GLIDE: Guided Lymphocyte Immunopeptide Derived Expansion). After donor cell collection, patients received fludarabine 30 mg/m2 and cyclophosphamide 300 mg/m2 for 3 days followed by infusion of GLIDE, consisting of donor T-lymphocytes expanded ex vivo following exposure to dendritic cells coated with immunogenic peptides (MiHAs) present on the surface of host hematopoietic cells, at a single target dose of 4x107 viable T-cells/m2. A second dose of GLIDE, aiming at 3-5 times the original dose, could be administered to patients at a minimum of 6 weeks after the first infusion. GLIDE cell characteristics were evaluated using multi-parameter flow cytometry and TCR sequencing. Patients were followed up for one year post-GLIDE infusion for toxicity and clinical outcome measures. Results Ten patients, median age of 58 (range 33-69), 4 females/6 males with AML (n=7), NHL (1), CLL (1), and myelofibrosis (1) were treated with GLIDE. These patients had relapsed at a median of 12 months (range 5-126 mo) after allogeneic HSCT. GLIDE cells were personalized to target single MiHAs in 9 patients and two MiHAs in 1 patient. Overall, GLIDE cell products were directed at 9 different MiHAs on 6 different HLA-class 1 molecules (HLA-A02:01, A24:02, B07:02, B18:01, B44:02, and B44:03). A first dose of GLIDE was administered at 4.0x107 CD3+ cells/m2 to 8 patients, and 2 patients received slightly lower doses (2.6 and 3.7 x 107 CD3+ cells/m2). Final GLIDE products consisted mainly of T-cells (median: 98,7%), with CD8>CD4>NKT>NK cells. Most CD8+ T cells were effector memory and central memory T cells (Figure 1). At the end of the expansion period, CD8+ T cells expressed activation markers (CD25+ = 67%) with low levels of PD1+, PDL1+, CD57+ and KLRG1+ as markers of exhaustion. Not surprisingly, GLIDE cells had a more restricted TCR β chain profile than initial lymphopheresis cells. Six patients received a second dose of GLIDE (mean: 12 x 107 CD3+ cells/m2) at 53 days after the first infusion (median, range: 48-118 days). There were no infusional toxicities, and cells were well-tolerated by patients. Only one patient developed thrombocytopenia and subsequent chronic GVHD. There were no other adverse events potentially related to GLIDE. According to TCR β sequencing data, T cells present in the adoptively transferred anti-MiHA GLIDE product persisted in peripheral blood up to one year after infusion. Survival at one year was observed in 4 patients with 3 patients in sustained remission (Figure 2). Conclusion This pilot study demonstrates the feasibility of anti-MiHA T cell ex vivo generation (GLIDE) and safety of its administration to patients relapsing after allogeneic HSCT, as well as the clinical potential of these cells. The persistent remissions and low occurrence of GVHD support further development of GLIDE to target acute myeloid leukemia and other hematologic malignancies. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Long-term outcome in patients with follicular lymphoma following high-dose therapy and autologous stem cell transplantation.

To contribute data on long-term outcome and potential curative impact of ASCT in FL, especially following HDT with the BEAM protocol (BCNU, etoposide, cytarabine and melphalan), given very limited data on this topic in the literature. Patients with FL (n=76) were treated in our institution with HDT and ASCT. In the case of long-term remission (≥8years), peripheral blood was tested for minimal residual disease by t(14;18)- and IGH-PCR, including the last follow-up. 10-year overall survival, progression-free survival, and freedom from progression (FFP) after first-line ASCT (n=20) were 80%, 60%, and 69%, after second-line ASCT (n=48, following BEAM) 66%, 38%, and 41%, after third/fourth-line ASCT (n=8) 33%, 25%, and 25%, respectively. Prognostic factors for FFP were treatment line and FLIPI (Follicular Lymphoma International Prognostic Index). 10-year FFP for second-line ASCT and low-risk FLIPI at relapse was 69%, intermediate-risk 28%, and high-risk 25% (P<.05). 26 patients developed sustained long-term clinical and molecular remissions of up to 27years. Sustained long-term clinical and molecular complete remissions up to 27years can be achieved following ASCT (including HDT with BEAM in second treatment line), indicating a potential curative impact of ASCT in FL.

Long-Term Clinical and Molecular Remissions in Patients with Follicular Lymphoma (FL) Following High-Dose Therapy (HDT) and Autologous Stem Cell Transplantation (ASCT)

Background: Long-term clinical and molecular remissions in patients with FL following HDT and ASCT have been evaluated in only a few studies. Results are especially limited for second-line HDT with BEAM (BCNU, etoposide, cytarabine and melphalan). Patients and methods: 73 patients with FL were treated in our institution from 1993 to 2016 (20 1st-line ASCT with total body irradiation (TBI) and cyclophosphamide, 46 2nd-line with BEAM and 8 ≥3rd-line with BEAM). Patients with high-grade transformation before ASCT were excluded. The data were collected retrospectively in 44 and prospectively in 29 patients who participated in two clinical trials: the 1st-line therapy trial of the German Low Grade Lymphoma Study Group (GLSG, principal investigator W. Hiddemann [Lenz G, Blood 2004]) and the salvage therapy LYM1 trial of the EBMT [Pettengell R, JCO 2013]. For the salvage ASCT protocol, most of the patients received 3 - 4 courses of the ESHAP or ICE protocol-since 2001, also usually combined with rituximab. Stem cell apheresis was carried out in the Blood Transfusion Service following these protocols or cyclophosphamide, usually in remission. Patients with partial remission after ASCT received a radiotherapy (RT) with 30-36 Gy in the field of persisting lymphoma, if possible, except participants of the LYM1 trial. Further details are described in an earlier publication of our first 60 patients (Metzner B, Ann Oncol 2013). Response assessment was performed by careful clinical examination (with ultrasound, chest x-ray and partly CT) at regular 3 - 12 monthly time points. In the case of long-term remission (≥ 8 years; n = 26), peripheral blood was tested for minimal residual disease by quantitative t(14;18) RQ-PCR and/or IGH-consensus PCR (n = 25). Results: With a median follow-up of 9.4 years (range 1.2-23.8) 10-year overall survival, progression-free survival and freedom from progression (FFP) after 1st-line ASCT were 80%, 60% and 68%, after 2nd-line ASCT 58%, 37% and 42%, after ≥3rd-line ASCT 50%, 25% and 25%, respectively, with a significant difference for OS, PFS and FFP between 1st-line and ≥3rd-line cohort, for PFS and FFP between 1st- and 2nd-line cohort (p<0.05). The median OS from the initial diagnosis for the 1st-line cohort and the 2nd-line cohort was not yet reached (estimated >23 years); and 9.4 years for the ≥3rd-line cohort; for a subgroup of the 2nd-line cohort with early relapse (time from diagnosis to 1st relapse maximum 24 months, n = 26) not yet reached (estimated >21 years). Ten-year FFP for 2nd-line ASCT and low-risk FLIPI score (n = 16) was 69%, intermediate risk (n = 11) 27% and high risk (n = 18) 29% (p=0.051). No relapses occurred after 8 years following ASCT in 1st or 2nd remission (except one patient 10 years after ASCT). So far, 26 patients developed long-term remissions of at least 8 years (up to 24, median 14 years). 24 of the 25 tested long-term remission patients were MRD-negative at the last follow-up. One patient was MRD-positive (low-level MRD) at the last control (10.6 years after ASCT in 1st line, unchanged as the years before). Five-year non-relapse mortality was 0%. Four of 73 patients developed secondary invasive malignancies in remission after ASCT: in the TBI cohort, 2 of 20 patients; in the BEAM cohort, 2 of 53 patients, (in the 2nd-line ASCT cohort 1 of 45 patients). Conclusion: Sustained long-term clinical and molecular remissions up to > 22 years can be achieved following ASCT in 1st or 2nd treatment line, indicating the potential curative impact of ASCT in FL. [Display omitted] DisclosuresPott:Janssen: 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.

Long-Term Clinical and Molecular Remissions in Patients with Mantle Cell Lymphoma (MCL) Following High-Dose Therapy (HDT) and Autologous Stem Cell Transplantation (ASCT)

Background:Long-term clinical and molecular remissions in patients with MCL following HDT and ASCT have been evaluated in only a few studies. Results are especially limited for remission duration over 5 years. So the curability of this disease remains an open question. Patients and methods:Altogether 61 patients with MCL were treated in our institution with ASCT from 1998 to April 2019 (50 1st-line ASCT, ten 2nd-line ASCT, one 3rd-line ASCT). The data were collected retrospectively in 29 and prospectively in 32 patients who participated in two clinical trials: the 1st-line therapy trials of the German Low Grade Lymphoma Study Group (GLSG, principal investigator W. Hiddemann [Dreyling M, Blood 2005] and the European Mantle Cell Lymphoma Network [Hermine O, Lancet 2016], respectively. The diagnosis was regularly approved by the reference pathology of the GLSG (W.K.). The induction therapy before 1st-line ASCT consisted of 6 courses CHOP (n=11), mostly combined with rituximab and followed by Dexa-BEAM, and 6 alternating courses of R-CHOP and R-DHAP (n=39), respectively. For the salvage treatment patients usually received three to four courses of the DHAP protocol or the ESHAP protocol, since 2001 also combined with rituximab.Stem cell apheresis was carried out in the Blood Transfusion Service following these protocols in remission. High-dose protocols: 1) total body irradiation with cyclophosphamide or melphalan and cytarabin (n=32) or 2) BEAM (n=29). Patients with partial remission after ASCT received a radiotherapy (RT) with 30-36 Gy in the field of persisting lymphoma, if possible (n=4). Since 09/2016 patients received a maintenance therapy with rituximab after ASCT (every 2 months, planned for 3 years, n=14). Further details are described in an earlier publication of our first 36 patients (Metzner B, Ann Hematol 2013). Response assessment was performed by careful clinical examination and by ultrasound, chest x-ray and partly CT at regular 3 - 12 monthly time points. In the case of long-term remission (≥ 5 years; n = 18), peripheral blood was regularly tested twice a year for minimal residual disease (MRD) by quantitative t(11;14) or allel specific IGH RQ-PCR and/or IGH-consensus PCR.Calculations were done using IBM SPSS Statistics Version 25. Data were analysed as of 01 July 2019. Results:With a median follow-up of 5 years (range 0.1-20) 10-year overall survival, progression-free survival (PFS) and freedom from progression (FFP) after 1st-line ASCT were 54%, 46% and 52%, respectively, after 2nd-line ASCT 42%, 20%and 20%, with a significant difference for PFS (p=0.045) and FFP (p=0.014) between 1st-line and 2nd-line cohort.Further prognostic factors (like sex, age, MIPI, bone marrow involvement, remission grade at ASCT: CR vs. PR, type of HDT: TBI vs. BEAM…) seemed to be without relevance (considering the small subgroups). Only one clinical relapse occurred after 5 years following ASCT in 1stor 2ndremission, respectively (one patient 6 years after 1st-line ASCT and another patient 7 years after 2nd-line ASCT and subsequent radiotherapy). So far, 18 patients experienced long-term remissions of at least 5 years (median 9 years, from 5 to 16 years). Fifteen of 17 tested patients were MRD negative at last follow-up, the two MRD positive patients (positive at a low level below the quantitative measuring range) had no clinical signs of relapse at last follow-up. None of these 18 patients had received rituximab maintenance therapy. None showed clinical criteria of "smoldering mantle cell lymphoma" at induction therapy. Treatment-related mortality at 100 days after ASCT was 1.6% (pneumonitis following TBI). One patient developed a secondary invasive malignancy in remission after ASCT (acute myeloid leukemia 4 years following TBI). Conclusion: Sustained long-term clinical and molecular remissions up to 16 years can be achieved following ASCT (without rituximab maintenance therapy), indicating the potential curative impact of 1st-line ASCT in MCL. The 2nd-line ASCT was obviously less effective. Disclosures Dreyling: Celgene: Consultancy, Other: scientific advisory board, Research Funding, Speakers Bureau; Janssen: Consultancy, Other: scientific advisory board, Research Funding, Speakers Bureau; Mundipharma: Consultancy, Research Funding; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: scientific advisory board, Research Funding, Speakers Bureau; Bayer: Consultancy, Other: scientific advisory board, Speakers Bureau; Gilead: Consultancy, Other: scientific advisory board, Speakers Bureau; Acerta: Other: scientific advisory board; Novartis: Other: scientific advisory board; Sandoz: Other: scientific advisory board. Klapper:Roche, Takeda, Amgen, Regeneron: Honoraria, Research Funding.

HTLV-1 Proviral Load after Two Months' Treatment with Anti-CCR4 Monoclonal Antibody Mogamulizumab Predicts a Molecular Response to Disease and Durable Clinical Remission in Leukaemic Subtypes of Adult T-Cell Leukaemia/Lymphoma

Background: Adult T-cell leukaemia/lymphoma (ATL) is an aggressive T-cell malignancy caused by HTLV-1 infection. Typically patients treated with chemotherapy show transient remissions followed by early relapse. There is a need for markers that can predict the response to therapy early in treatment in order to stratify patients who should be considered early for alternative therapies including allogeneic transplantation. The 0761-009 study was a multi-centre, open-label, randomised study of anti-CCR4 monoclonal antibody mogamulizumab (KW-0761) or investigator's choice of chemotherapy in subjects with previously treated, relapsed or refractory ATL. Here we report longitudinal data on proviral load (PVL) and clonal abundance from 4 subjects treated in the UK with leukaemic-type disease (3 chronic, 1 acute subtype).Methods: qPCR was undertaken to measure PVL and high-throughput sequencing (HTS) to quantify the abundance of the malignant clone, using our previously reported protocols.Results: Two patients with chronic ATL were randomised to receive mogamulizumab and two patients (one chronic, one acute subtype) to receive chemotherapy (gemcitabine/oxaliplatin). The chemotherapy-treated patients both progressed early and therefore crossed over to mogamulizumab treatment. The three patients with chronic subtype ATL achieved a haematological remission before the end of cycle 1 (28 days therapy), and the patient with acute subtype achieved remission by the end of cycle 2. The median PVL of the 4 patients was 61.4% on trial entry, rising to 88.1% prior to first mogamulizumab infusion. By the end of cycle 2, the median PVL fell to 0.43% (range 0.11 - 28%). The median number of mogamulizumab cycles was 16 (range 2-30). All 3 patients with chronic ATL achieved a PVL <1% prior to the end of cycle 2 and were discontinued due to toxicity: one patient discontinued after cycle 2 (pneumonitis) but remained in clinical remission for 14 months off all treatment. One patient discontinued treatment after 16 cycles with a skin rash, initially considered to be cutaneous ATL, whic was treated topically with steroids, and remains in leukaemic remission two years off all treatment. Finally, one patient discontinued in July 2016 after 31 cycles of treatment, due to skin hypersensitivity, and remains in remission. The patient with acute subtype showed a normalisation of the lymphocyte count within a few weeks and had a normal PETCT scan, but did not show a significant reduction in PVL (44% baseline, 41% at end of Cycle 2). This patient continued in leukaemic remission for 16 months but developed an intraparotid localised nodal progression whilst on mogamulizumab treatment. HTS showed that long-term clinical responses were also associated with a 4-5 log reduction in the absolute abundance of the malignant clone.Conclusions: Three patients with unfavorable chronic type of ATL achieved durable clinical remissions following treatment with mogamulizumab, and first experienced rapid normalisation of the lymphocyte count (2-4 weeks) followed by a ~ 2 log reduction in the PVL (to <1%) before the end of the 2nd cycle. In the chronic patients who tolerated treatment for long enough to achieve 4-5 log reductions in the absolute abundance of the malignant clone, durable remissions were maintained offtherapy. HTS can be used to quantify molecular responses to treatment and in this small group of patients achieving a proviral load <1% and a 4-5 log reduction in the absolute abundance of the malignant clone was associated with long-term clinical remissions. DisclosuresCook:Kyowa Kirin Pharmaceutical Development, Inc.: Consultancy.

AhR ligand Aminoflavone inhibits α6-integrin expression and breast cancer sphere-initiating capacity

Traditional chemotherapies debulk tumors but fail to produce long-term clinical remissions due to their inability to eradicate tumor-initiating cells (TICs). This necessitates therapy with activity against the TIC niche. Αlpha6-integrin (α6-integrin) promotes TIC growth. In contrast, aryl hydrocarbon receptor (AhR) signaling activation impedes the formation of mammospheres (clusters of cells enriched for TICs). We investigated the ability of AhR agonist Aminoflavone (AF) and AF pro-drug (AFP464) to disrupt mammospheres derived from breast cancer cells and a M05 mammary mouse model of breast cancer respectively. We further examined the capacity of AF and AFP464 to exhibit anticancer activity and modulate the expression of ‘stemness’ genes including α6-integrin using immunofluorescence, flow cytometry and qRT-PCR analysis. AF disrupted mammospheres and prevented secondary mammosphere formation. In contrast, AF did not disrupt mammospheres derived from AhR ligand-unresponsive MCF-7 cells. AFP464 treatment suppressed M05 tumor growth and disrupted corresponding mammospheres. AF and AFP464 reduced the expression and percentage of cells that stained for ‘stemness’ markers including α6-integrin in vitro and in vivo respectively. These data suggest AFP464 thwarts bulk breast tumor and TIC growth via AhR agonist-mediated α6-integrin inhibition.

Temozolomide Therapy for Aggressive Pituitary Tumors: Results in a Small Series of Patients from Argentina.

We evaluated results of temozolomide (TMZ) therapy in six patients, aged 34–78 years, presenting aggressive pituitary tumors. In all the patients tested O6-methylguanine-DNA methyltransferase (MGMT) immunoexpression in surgical specimens was absent. Patients received temozolomide 140–320 mg/day for 5 days monthly for at least 3 months. In two patients minimum time for evaluation could not be reached because of death in a 76-year-old man with a malignant prolactinoma and of severe neutro-thrombopenia in a 47-year-old woman with nonfunctioning pituitary adenoma. In two patients (a 34-year-old acromegalic woman and a 39-year-old woman with Nelson's syndrome) no response was observed after 4 and 6 months, respectively, and the treatment was stopped. Conversely, two 52- and 42-year-old women with Cushing's disease had long-term total clinical and radiological remissions which persisted after stopping temozolomide. We conclude that TMZ therapy may be of variable efficacy depending on—until now—incompletely understood factors. Cooperative work on a greater number of cases of aggressive pituitary tumors should be crucial to establish the indications, doses, and duration of temozolomide administration.

Abstract 215: Aminoflavone exhibits in vivo efficacy on cancer stem cells in a spontaneous estrogen-dependent breast cancer murine model

Abstract Stem-cell populations have been identified in a range of solid tumors and possess the capacity to self renew. It is thought that these cancer stem cells (CSCs) play an important role in cancer establishment, progression, and resistance to current treatments. CSCs have been identified in primary breast cancer tissues and cell lines derived from metastatic tumors. Traditional cancer therapies are effective at debulking some tumors but often fail to produce long-term clinical remissions, presumably due to their inability to eradicate the cancer stem cell population. Therefore, novel treatments aimed at targeting this population can potentially enhance treatment of both primary and metastatic tumors. Aminoflavone (AF; NSC 686288) is a novel anticancer agent. Previous work from our research group demonstrated that AF is a ligand of the aryl hydrocarbon receptor (AhR) and displays cytotoxicity in the MCF-7 breast cancer cell line. A prodrug formulation of AF (AFP464, NSC710464), recently entered phase II clinical trials. Moreover, we previously found that AF disrupts MCF-7 mammosphere formation via AhR signaling activation to inhibit alpha 6-integrin expression. To investigate the efficacy of AF in vivo, we used an estrogen dependent, Tamoxifen-sensitive spontaneous M05 model system involving 1-year-old virgin female BALB/c mice developed in our animal facility. The M05 tumor is a semi-differentiated adenocarcinoma that expresses estrogen and progesterone receptors. After AF treatment (12 mg/kg, i.p., QD × 5 days) tumor size and growth rate decreased substantially compared to control animals. Cytometric analyses of cells obtained from AF-treated and control animals revealed that Lin (-)/ CD29 (Hi)/CD24 (+) cancer stem cells were lower in animals treated with AF than in the vehicle control group. We also observed a diminished capacity for mammosphere formation in cells obtained from tumors treated with AF. These data suggest AF diminishes the quantity of breast cancer stem cells as well as their integrity and capacity to form mammospheres in vitro and in vivo. These findings shed additional insight into the molecular mechanism of anticancer action for this novel anticancer agent to strengthen the rationale for its inclusion in breast cancer treatment regimens. Citation Format: Mariana Callero, Damian Berardi, Laura Todaro, Marina Simian, Eileen J. Brantley, Ubaldo Soto, Andrea Loaiza-Perez. Aminoflavone exhibits in vivo efficacy on cancer stem cells in a spontaneous estrogen-dependent breast cancer murine model. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 215. doi:10.1158/1538-7445.AM2014-215

Long-term clinical and molecular remissions in patients with mantle cell lymphoma following high-dose therapy and autologous stem cell transplantation

Long-term clinical and molecular remissions in patients with mantle cell lymphoma (MCL) following high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) have been evaluated in only a few studies. Thirty-six patients with MCL received ASCT in our institution (27 patients undergoing first-line therapy, 8 patients undergoing second-line therapy, and 1 patient undergoing third-line therapy). In the case of long-term remission (≥5years; n = 8), peripheral blood was tested for minimal residual disease (MRD) by t(11; 14) polymerase chain reaction (PCR) and immunoglobulin heavy-chain (IGH) PCR at the last follow-up. Ten-year overall survival (OS), progression-free survival (PFS), and freedom from progression (FFP) after first-line ASCT were 42%, 43%, and 54%; after second-line ASCT, these were all 0%. Four-year OS, PFS, and FFP for the first-line cohort were 75%, 48%, and 61%, respectively. Four-year OS, PFS, and FFP after second-line ASCT were 55%, 30%, and 30%, respectively. Treatment-related mortality (3months after ASCT) was 0%. The only prognostic factor for OS, PFS, and FFP was treatment line (p = 0.011, p = 0.046, and p = 0.023, respectively). No relapses occurred after 5years following ASCT. So far, eight patients developed sustained long-term clinical and molecular complete remissions of up to 14.6years following ASCT in the first treatment line. Sustained long-term clinical and molecular remissions can be achieved following ASCT in the first treatment line and apparently less frequent in the second treatment line.

Long-term clinical and molecular remissions in patients with follicular lymphoma following high-dose therapy and autologous stem cell transplantation

BackgroundLong-term clinical and molecular remissions in patients with follicular lymphoma (FL) following high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) have been evaluated in only a few studies. Results are especially limited for second-line HDT with BEAM (BCNU, etoposide, cytarabine and melphalan). Patients and methodsSixty patients with FL received ASCT in our institution (18 first-line with total body irradiation and cyclophosphamide, 34 second-line with BEAM and 8 ≥third-line with BEAM). In the case of long-term remission (>6 years; N = 17), peripheral blood was tested for minimal residual disease by t(14;18)- and IGH-PCR. ResultsTen-year overall survival, progression-free survival and freedom from progression (FFP) after first-line ASCT were 79%, 57% and 64% after second-line ASCT 41%, 35% and 42%, respectively. Prognostic factors for FFP were treatment line and FLIPI (Follicular Lymphoma International Prognostic Index). Ten-year FFP for second-line ASCT and low-risk FLIPI was 57%, intermediate risk 37% and high risk 33%. No relapses occurred after 6 years following ASCT. Sixteen patients developed sustained long-term clinical and molecular remissions of up to 17.5 years. ConclusionSustained long-term clinical and molecular remissions can be achieved following ASCT, including HDT with BEAM in second line.

Advances in current treatment for patients with newly diagnosed multiple myeloma

Multiple myeloma (MM) is a hematologic malignancy characterized by the proliferation of monoclonal plasma cells at multiple sites in the bone marrow, with accompanying alterations in the bone marrow microenvironment, and suppression of the host antitumor immune response, resulting in the uncontrolled accumulation of malignant plasma cells and excess secretion of immunoglobulins (paraproteins). MM, in almost all cases, is preceded by a premalignant phase, monoclonal gammopathy of undetermined significance (MGUS).1 MGUS is present in ∼3% of the population aged >50 years and progresses through asymptomatic smoldering myeloma to symptomatic MM at a rate of 1% annually.2 MM is usually diagnosed when the disease becomes symptomatic, classically presenting with bone pain, anemia, renal insufficiency, hypercalcemia and recurrent infections due to immune deficiency. MM has an annual age-adjusted incidence of 5.8 cases per 100 000 of the population and predominantly affects older individuals; the median age at diagnosis is 69 years.3, 4 MM is an incurable disease and the survival prognosis for patients diagnosed with MM has historically been poor. The introduction of high-dose chemotherapy (HDT) followed by autologous stem cell transplantation (ASCT) in the 1980s improved response rates and progression-free survival (PFS), but median overall survival (OS) remained at 65 years for whom OS is only 26 months.8 The treatment of MM in elderly patients remains a clinical challenge—they are usually ineligible for stem cell transplantation and are unable to tolerate the toxicity of intense chemotherapy. Besides age at diagnosis and disease stage, prognosis is also adversely affected by the presence of several ‘high-risk' genetic markers, including deletions of chromosome 13, hypodiploidy and deletions of chromosome 17p, t(4;14) or t(14;16).2 Significant improvements in response rates, PFS and OS have been seen in patients with NDMM treated with combination regimens based on immunomodulatory drugs (thalidomide and lenalidomide) and proteasome inhibitors (bortezomib).9, 10, 11, 12, 13, 14, 15, 16 These advances, coupled with an improved understanding of the disease, have shifted the treatment paradigm in MM. The current aim of this therapy for patients with NDMM is to achieve deep and long-term clinical remissions with early and continued use of regimens that are effective and safe to maintain disease control and extend OS. The purpose of this supplement is to review current approaches to the treatment of NDMM, providing an update on the most recent developments and treatment regimens involving the novel therapies, and highlighting the key issues that clinicians face when devising a long-term management strategy for NDMM patients. In the first article, Drs Munshi and Girnius provide an overview of the current approaches related to the diagnosis and management of MGUS, smoldering MM and MM, highlighting the need for a long-term approach to optimize disease control and the importance of a risk-stratified approach to treatment. In the second article, Drs Giralt and Bensinger discuss the role of ASCT and the role of novel therapies in induction treatment. The question of how to optimize the response to ASCT using consolidation therapy with novel agents is then addressed by Drs Moreau and Touzeau, including a review of recent clinical evidence showing the benefit of post-transplantation maintenance treatment with novel agents to extend PFS. Finally, Professor San Miguel and Dr Mateos provide an overview of the treatment options available for NDMM patients ineligible for HDT–ASCT because of either advanced age or comorbid conditions. Again, the focus is on the way in which the novel therapies have transformed the treatment options available to this population, who represent the majority of NDMM patients. In this setting, early and continued treatment with novel agents appears to have the potential to extend survival times for elderly and frail patients for whom outcomes have remained poor. Collectively, these articles illustrate how the introduction of novel agents, such as lenalidomide and bortezomib, has transformed the approach to treatment of NDMM and has provided a valuable clinical update for those working in this field.

Autologous haematopoietic stem cell transplantation for systemic lupus erythematosus: data from the European Group for Blood and Marrow Transplantation registry

Patients with systemic lupus erythematosus (SLE) refractory to conventional immunosuppression suffer substantial morbidity and mortality due to active disease and treatment toxicity. Immunoablation followed by autologous stem cell transplantation (ASCT) is a novel therapeutic strategy that potentially offers new hope to these patients. This retrospective survey reviews the efficacy and safety of ASCT in 28 SLE patients from eight centres reported to the European Group for Blood and Marrow Transplantation (EBMT) registry between 2001 and 2008. Median disease duration before ASCT was 52 (nine to 396) months, 25/28 SLE patients (89%) were female, age 29 (16-48) years. At the time of ASCT, eight (one to 11) American College of Rheumatology (ACR) diagnostic criteria for SLE were present and 17 (60%) patients had nephritis. Peripheral blood stem cells were mobilized with cyclophosphamide and granulocyte-colony stimulating factor in 93% of patients, and ex vivo CD34 stem cell selection was performed in 36%. Conditioning regimens were employed with either low (n = 10) or intermediate (18) intensities. With a median follow-up of 38 (one to 110) months after ASCT, the five-year overall survival was 81 ± 8%, disease-free survival was 29 ± 9%, relapse incidence (RI) was 56 ± 11% and non-relapse mortality was 15 ± 7%. Graft manipulation by CD34+ selection was associated with a lower RI (p = 0.001) on univariate analysis. There were five deaths within two years after ASCT: three caused by infection, one by secondary autoimmune disease and one by progressive SLE. Our data further support the concept of immunoablation and ASCT to re-induce long-term clinical and serologic remissions in refractory SLE patients even in the absence of maintenance therapy. This study also suggests a beneficial effect of ex vivo graft manipulation on prevention of relapses post-transplantation in SLE.

Novel agents and the paradigm of continuous treatment in multiple myeloma

Multiple myeloma (MM) is a hematologic malignancy that primarily affects those aged >65 years [1]. The disease remains incurable despite major advances in treatment, such as highdose therapy followed by autologous stem-cell transplantation (ASCT), and the availability of novel anti-myeloma agents such as thalidomide, lenalidomide, and bortezomib. Introduction of these novel agents has greatly extended survival times in MM patients [2,3]; however, long-term remissions are rare and outcomes in elderly transplant-ineligible patients in particular remain poor [4]. In most patients, MM is characterized by a progressive pattern of treatment and relapse that leads to the development of an advanced, treatment-refractory disease. Most patients with MM eventually relapse due to the existence of clonogenic, residual MM cells, which persist even in those who clinically show a complete response to treatment. Therefore, a focus of current clinical research is the identification of treatment approaches that are able to suppress residual MM cells and delay progression of the disease. Treatment regimens based on the novel agents thalidomide, lenalidomide, and bortezomib are effective in patients with newly diagnosed MM [5–8], and in those with relapsed/refractory disease [9–12]. However, the optimal duration of treatment in MM patients has not been defined and the duration of treatment is individualized. In this context, continuous therapy with novel agents is being evaluated as a strategy for longterm disease control across lines of treatment. The concept being evaluated is whether continuous treatment with a novel agent, either alone or in combination with other treatments, can lead to long-term clinical remissions. The recently reported results of the MM-015 trial [7], which evaluated continuous lenalidomide therapy in elderly patients with newly diagnosed MM, have sparked new interest in continuous therapy and raised several important practical questions regarding its integration into current practice. To address these issues, I developed the concept of a journal supplement devoted specifically to the topic of continuous therapy and invited some of my distinguished colleagues to contribute articles to the supplement. A journal supplement seemed to be an appropriate medium to consolidate the available evidence, address a wide range of issues related to the topic, and provide different perspectives from experts in the field of MM therapy.

Isolation of human anti-MICA antibody from cancer patients responding to immunotherapies.

2502 Background: Immunotherapy is a promising modality for the treatment of cancer, and elucidating the mechanism of action is crucial to guiding patient selection and developing future immunotherapeutic strategies. Engagement of the immune molecule NKG2D by the cancer antigen MICA is important for immune surveillance of many cancers. Tumors can evade immune surveillance by shedding cell surface MICA, which leads to dampening of anti-tumor immunity. Investigations by our laboratory revealed that patients responding to immunotherapy can mount antibody responses targeting MICA, which permits re-engagement of immunity. Methods: Patients with advanced cancer treated at our institution with immunotherapies (tumor cell vaccination, ipilimumab) were identified, including several with long-term clinical remissions. Plasma was analyzed for MICA reactivity to three distinct MICA alleles, and rare memory B cells reactive to MICA were isolated using tetramerized MICA protein. Immunoglobulin heavy and light chain variable domains were sequenced with single cell RT-PCR to generate recombinant monoclonal antibody. Results: Plasma from patients treated with immunotherapy revealed considerable inter-patient variation in reactivity to MICA. Patients with marked plasma reactivity (including several with sustained clinical remissions) were selected for isolation of rare memory B cells reactive to MICA. From these cells, we have generated a recombinant fully-human MICA-reactive monoclonal antibody that exhibits binding to a variety of MICA alleles. Conclusions: We have developed novel methods to analyze anti-MICA antibody responses and isolate rare memory B cells from cancer patients who gained significant clinical benefit from immunotherapy. This has facilitated the generation of fully human recombinant anti-MICA monoclonal antibody. To our knowledge, this is the first example of a specific antibody reactive to a cancer antigen isolated from a cancer patient responding to immunotherapy. As these antibody responses likely played a role in tumor destruction, these results inform the development of new antibody-based immunotherapies targeting the NKG2D-MICA pathway.

The Majority of Patients Receiving Donor Lymphocyte Infusions for Relapsed Chronic Myeloid Leukemia Remain PCR Positive Despite Maintaining Long-Term Remission,

Abstract 4103Donor lymphocyte infusions (DLI) produce molecular remission in the large majority of chronic myeloid leukaemia (CML) patients who relapse after allografting. Although response to DLI is associated with long-term clinical remissions, we asked whether minimal residual disease could still be detected. We identified 116 patients who had received escalating doses of donor lymphocytes between 1995 and 2010 for molecular, cytogenetic or haematological relapse following allogeneic hematopoietic stem cell transplantation for CML. These patients had serial monitoring of their response by quantitative reverse transcriptase–polymerase chain reaction (RT-PCR). 84 patients had achieved a complete molecular remission (CMR) (defined by 2 consecutive negative PCR), however 79 (94%) of these subsequently became positive again. All patients who achieved a complete molecular remission were allocated to 3 categories: (1) “persistently negative” or a single low level positive result (n=15 (18%); (2) “fluctuating low-level positive”, who had multiple positive results, but never more than 2 consecutive positive results (n=34 (40%)); and (3) “persistently low-level positive” (n=35(42%)), and the rates of relapse were compared in the three groups. The overall probability of relapse (defined by the initial molecular relapse criteria) at 10 years was low in all three groups (6.7%), and there was no significant difference in each category: 0%, 4.2% and 10.3% respectively (P=0.372) (figure 1), with no survival difference in the three groups. Furthermore, of the 32 patients who did not achieve a CMR, 11 achieved a fall in PCR to <0.1 (major molecular remission (MMR)) following completion of their DLI protocol and had a non-inferior survival to those who achieve a CMR, in contrast to those who did not satisfy either of these criteria, and had a significantly inferior survival (p<0.01) (figure 2). We conclude that the majority of patients who respond to DLI do not remain PCR negative, but low-level positive results do not predict relapse. This suggests that, although DLI does not completely eradicate the disease, it exerts a highly effective long-term disease control. The data presented also raises the question of whether persistent PCR negativity should be unequivocally pursued, or whether a threshold of MMR may be adequate. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Treatment of Juvenile Pemphigus Vulgaris with Intravenous Immunoglobulin Therapy

We report the clinical response and follow-up on eight patients with juvenile pemphigus vulgaris treated with intravenous immunoglobulin. Six Caucasian females and two Caucasian males ages 15 to 18 (mean 15.5) were treated with intravenous immunoglobulin based on a published protocol. The indications were lack of response and development of serious side-effects to conventional therapy in four, lack of response to dapsone in two, and parental choice in two patients. In seven patients, a prolonged clinical remission was achieved. They received a mean of 28.5 cycles of intravenous immunoglobulin in a mean of 43.4 months and were followed for a mean of 29.8 months after discontinuing treatment. The remaining patient responded, but was lost to follow-up. Mean follow-up was 71.7 months. Six patients experienced mild headache, but no serious side-effects were observed in any patient. Intravenous immunoglobulin is a safe biological agent to use in the treatment of juvenile pemphigus vulgaris. It can be used as monotherapy and has the potential to induce and sustain long-term clinical remissions. In these eight patients, it appears that intravenous immunoglobulin is a safe biological agent without serious, immediate, or long-term side effects. Intravenous immunoglobulin is a valuable agent in the treatment of certain cases of juvenile pemphigus vulgaris.

Intensivierte Therapie des schweren Lupus erythematodes

14 female patients (mean age 28 [18-56] years) with severe systemic lupus erythematosus (SLE) were treated after discontinuing previous immunosuppressive therapy, according to an intensified protocol, with three plasmaphereses (days 1-3), followed by pulse cyclophosphamide (12 mg/kg i.v. each on days 3-5) and then oral immunosuppression (cyclophosphamide 1-5 mg/kg daily, depending on white blood cell count; prednisone equivalent 2.0 decreasing to 0.1 mg/kg, according to response, for 6 months). The aim of "synchronization" of plasmaphereses with subsequent cyclophosphamide pulse-therapy is to damage pathogenic lymphocyte clones during maximal compensatory activation induced by plasmapheresis. In all patients there was rapid improvement from the nephritis, pneumonitis, cytopenia, CNS abnormalities and polyserositis. The lupus activity index (SLAM) fell clearly, from initially 28.4 (13-37) points to 8.9 (2-13) after 6 months. Treatment was discontinued after this fall in 12 patients. A recurrence was observed in two patients, at 12 and 39 months respectively. Another patient died from liver cirrhosis of unknown aetiology. Nine patients are under observation but without treatment at present, in essential remission after 2 years (5-51 months), with a SLAM of 2.8 (0-7) points. "Synchronization" of plasmaphereses with subsequent pulse cyclophosphamide achieved rapid improvement and it resulted, for the first time, repeatedly in long-term treatment-free clinical remissions.

The allogeneic dilemma

The place of allogeneic SCT in the management of multiple myeloma remains controversial. Although it may induce long-term clinical and molecular remissions, the very high transplant-related toxicity after a myeloablative preparative regimen has limited its role to younger patients as first-line treatment option. Even with this limited indication, toxic death rate related to infections and GVHD is considered too high and this strategy has been almost abandoned. Reduced intensity conditioning (RIC) regimens look promising, as the transplant-related mortality is low even with matched unrelated donors and can be considered for older patients up to the age of 65 years. However when used in patients with a high tumor burden or with chemo-resistant disease, the immunologic effect of the graft is not sufficient to avoid relapses. Therefore, RIC allotransplantation is currently used after tumor mass reduction with high-dose therapy followed by autologous SCT. A recently published Italian study shows that this strategy induces better event-free survival than double autologous SCT due to a reduced relapse rate. The questions raised by this encouraging result are discussed in this paper.