Peripheral T-cell non-Hodgkin Lymphoma Research Articles

First-Line Therapy for Nodal T-cell Non-Hodgkin Lymphomas: an Unmet Need in Hematology.

The main aim of this review is to summarize first-line therapy of nodal T-cell non-Hodgkin lymphoma. Current treatment with CHOP chemotherapy results in poor outcomes in the majority of patients. However, there are advances within the field. First breakthrough is the ECHELON-2 trial which showed that the addition of brentuximab vedotin improves outcomes in anaplastic large cell lymphoma. However, other types of peripheral T-cell non-Hodgkin lymphoma were underrepresented with optimal treatment not known. Second breakthrough is an increase of autologous stem cell transplantation usage in the first complete metabolic remission, except in ALK + anaplastic large cell lymphoma, offering better disease control. Despite advances in the field, CHOP remains the standard treatment for the majority of these lymphomas, but multiple trials are underway with the aim to improve this unmet need in hematology and, hopefully, leading us to a new era in the treatment of peripheral T-cell lymphomas.

Coexistence of T-Large Granular Lymphocyte Leukemia and Peripheral T Cell Lymphoma-NOS with indolent behaviour

T-cell lymphomas and leukemias are highly heterogeneous groups of rare disorders. We report a case of a 68-year-old man patient who developed two different T-cell neoplasms (Large Granular Lymphocyte Leukemia [LGLL] in 2018 and Peripheral T-cell non-Hodgkin lymphoma not otherwise specified [PTCL-NOS] in 2019) with a previous diagnosis of B-cell marginal zone lymphoma in 2010, treated with two lines of chemo-immunotherapy. The coexistence of these different T-cell neoplasms is rarely reported in the literature. Moreover, it is usually described as an LGLL transformation into PTCL-NOS; differently from these examples, herein, the simultaneous conditions appear to be driven by different T-cell clones. Furthermore, the PTCL-NOS had quite unusual behavior, with good disease control without intensive treatment. Because of these features, it could belong to a subgroup of indolent PTCL-NOS, not yet described in the WHO classification of T-cell neoplasms, which could benefit from less aggressive treatment.

Cepp in Previously Untreated Patients with Mature T Cell Lymphomas

▪IntroductionThere is currently no standard of care for the upfront management of patients with mature T cell non-Hodgkin lymphomas (T-NHL). The role of anthracyclines in the treatment of T-NHL remains unclear and is also associated with significant toxicity. CEPP (cyclophosphamide, etoposide, procarbazine, and prednisone), a non-anthracycline regimen, is an effective salvage regimen for relapsed/refractory NHL and has shown a favourable toxicity profile. Since 2005, CEPP has been used in Singapore in the upfront treatment of T-NHL patients either with a contraindication to anthracyclines or at physicians' discretion. Our study aimed to assess the efficacy of CEPP in the upfront treatment of T-NHL.MethodsA retrospective study of all patients with newly diagnosed T-NHL treated with CEPP with curative intent from 2005-2021 was undertaken across 2 national cancer centers in Singapore. Outcomes of this population was also compared with a 1:1 control group treated with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) in the same time period, and matched for age, T-NHL subtype, clinical stage and international prognostic index (IPI). Patient demographics, disease characteristics and clinical outcomes (progression free survival, PFS and overall survival, OS) were evaluated. None of the patients had upfront autologous transplantation.ResultsWe identified 34 patients treated with CEPP who met the inclusion criteria. Clinical characteristics were as follows: Median age was 71 (range 39-85), 24 (71%) were male, 26 (76%) had advanced disease (Stage III-IV) and 21 (62%) had a high intermediate or high risk IPI ( IPI 3, 14 (41%) and IPI 4-5, 21 (21%)). The most common T-NHL subtypes were peripheral T-NHL (PTCL-NOS) not otherwise specified, 11 (32%) as well as angioimmunoblastic T cell lymphoma (AITL), 16 (47%). At a median follow up of 20 months (range 2-197months), the median PFS and OS were 17.6mths and 37.2mths respectively for the CEPP group. 15/34 (44%) CEPP patients have died (8 with lymphoma, 2 from treatment toxicity and 5 from unrelated causes). In the matched control comparison, the 5yr PFS and OS were both similar for patients treated with CEPP compared to patients in the CHOP control group, PFS 30% vs 32%, p= 0.43 and OS 47% vs 52%, p = 0.32, respectively (Figure 1)ConclusionOur findings show that CEPP is a well-tolerated regimen which can cure a proportion of patients with T-NHL even without autologous transplantation consolidation. Outcome of these patients do not seem to be significantly different compared to a similar population treated with standard CHOP. This study supports CEPP as a tolerable treatment option for selected patients who cannot tolerate anthracyclines and as an alternative to CHOP regimen for older patients who are not planned for ASCT. [Display omitted] DisclosuresJeyasekharan: Turbine Ltd: Consultancy; Janssen: Consultancy, Research Funding; AstraZeneca: Consultancy, Research Funding; Perkin Elmer: Other: travel funding ; MSD: Consultancy.

Role of lenalidomide in the treatment of peripheral T-cell non-Hodgkin lymphomas.

T-cell lymphomas (TCLs) represent a group of lymphoid neoplasms characterized by an aggressive clinical course, even after an anthracycline-containing regimen. Novel agents for patients with relapsed/refractory TCL are urgently needed. Lenalidomide is an oral drug with immunomodulatory, antiangiogenic and direct antineoplastic effects. These peculiar mechanisms of action make TCL an attractive target for lenalidomide. We have identified five clinical trials in which lenalidomide monotherapy was investigated to treat TCL, including cutaneous TCL (CTCL) and adult T-cell lymphoma/leukemia (ATLL). In the ATLL-002 study, the overall response rate (ORR) was 42% and median progression-free survival (PFS) and overall survival were 3.8 mo and 20.3 mo, respectively. In a phase II trial for CTCL, ORR was 28% and median PFS and overall survival were 8 mo and 43 mo, respectively. For nodal peripheral TCL, ORR was between 10% and 43% in three clinical trials, with a median PFS of about 4 mo, even if some patients had a durable response. Overall toxicity is manageable and grade 3-4 events are mainly hematological and reversible. Combination strategies did not improve PFS. In conclusion, lenalidomide could represent a suitable treatment option for relapsed/refractory TCL, especially for neoplasms with a T-follicular helper origin, such as angioimmunoblastic TCL.

A randomized phase 3 trial of autologous vs allogeneic transplantation as part of first-line therapy in poor-risk peripheral T-NHL

AbstractFirst-line therapy for younger patients with peripheral T-cell non-Hodgkin lymphoma (T-NHL) consists of 6 courses of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) with or without etoposide (CHOEP), consolidated by high-dose therapy and autologous stem cell transplantation (auto-SCT). We hypothesized that allogeneic stem cell transplantation (allo-SCT) could improve outcomes. 104 patients with peripheral T-cell non-Hodgkin lymphoma, except ALK+ anaplastic large cell lymphoma, 18 to 60 years, all stages, and all age adjusted International Prognostic Index scores, except 0 and stage I, were randomized to 4 cycles of CHOEP and 1 cycle of dexamethasone, cytosine-arabinoside, and platinum (DHAP) followed by high-dose therapy and auto-SCT or myeloablative conditioning and allo-SCT. The primary end point was event-free survival (EFS) at 3 years. After a median follow-up of 42 months, the 3-year EFS after allo-SCT was 43%, as compared with 38% after auto-SCT. Overall survival at 3 years was 57% vs 70% after allo- or auto-SCT, without significant differences between treatment arms. None of the 21 responding patients proceeding to allo-SCT relapsed, as opposed to 13 of 36 patients (36%) proceeding to auto-SCT. Eight of 26 patients (31%) and none of 41 patients died of transplant-related toxicity after allo- and auto-SCT, respectively. The strong graft-versus-lymphoma effect after allo-SCT was counterbalanced by transplant-related mortality. This trial is registered at www.clinicaltrials.gov as #NCT00984412.

Aberrant CD3-Positive, CD8-Low, CD7-Negative Lymphocytes May Appear During Viral Infections and Mimic Peripheral T-Cell Lymphoma.

Flow cytometry (FC) facilitates diagnosis of peripheral T-cell non-Hodgkin lymphoma (T-NHL), but overlapping features between reactive and neoplastic T-cell proliferations often hamper a rapid assessment. One hundred forty peripheral blood samples submitted to diagnostic FC for T-cell immunophenotyping were retrospectively analyzed. A T-cell population with a conspicuous aberrant surface epitope expression pattern was observed in 18 cases and diagnostic follow up was performed. The aberrant T-cell population exhibited a low scatter profile, a CD7-negative/low, CD8-low and CD3-positive immunophenotype, and monoclonal T-cell receptor expansion. T-NHL was ruled out by follow up in all cases. Epstein-Barr virus infection was diagnosed in 12 cases, cytomegalovirus infection in three cases; one patient had been vaccinated. The irregular subpopulation disappeared spontaneously within days or weeks. We describe a novel peripheral blood T-cell subpopulation with a low light scatter and CD8-low, CD7-negative/low and CD3-positive marker expression profile, which indicates reactive T-cell expansion in patients who present with peripheral lymphadenopathy and/or B symptoms.

The prognostic value of toll-like receptor5 and programmed cell death-ligand1 in patients with peripheral T-cell non-Hodgkin lymphoma

TLR5 is expressed in a variety of tumors. However, the clinical impact of TLR5 in Peripheral T-cell non-Hodgkin lymphomas (PTCLs) remains unclear. We analyzed differentially expressed genes in PTCLs samples from Gene Expression Omnibus database. We examined TLR5 and programed cell death-ligand1 (PD-L1) expression by immunohistochemistry in PTCLs tissues. Gene expression profiling shown PD-L1 and TLR5 expression was higher in PTCLs than in normal samples. The rates of high TLR5 and PD-L1 expression were 12.5% and 45.8%. We found association between TLR5 and PD-L1 expression. Low TLR5 expression or high PD-L1 expression was correlated with shorter overall survival and inferior disease-free survival. Multivariate Cox regression analysis shown low TLR5 expression, high PD-L1 expression, gender, and high IPI score were prognostic factors (p < .05). PTCLs patients with low TLR5 expression and high PD-L1 expression had worse prognosis. TLR5 and PD-L1 may serve as potential therapeutic targets in PTCLs patients.

A phase II study of a modified hyper-CVAD frontline therapy for patients with adverse risk diffuse large B-cell and peripheral T-cell non-Hodgkin lymphoma

To improve complete remission (CR) rates by reducing toxicity and enhancing delivery, we created a modified hyper-CVAD/MA regimen (cyclophosphamide, vincristine, doxorubicin, dexamethasone/methotrexate, cytarabine) by reducing the cytarabine dose (3 g/m2 to 2 g/m2) and number of cycles (eight to six). We conducted a phase II trial in the pre-rituximab era in the intermediate–high international prognostic index (IPI) (≥2) de novo diffuse large B-cell lymphoma (DLBCL) and peripheral T-cell lymphoma (PTCL) (ACTRN12605000105640). CR rates were compared with reported IPI-stratified rates. Sixty-three patients (n = 26 PTCL; n = 37 DLBCL) were evaluated; median follow-up of 30 months. CR rates for PTCL and DLBCL patients were 46% and 49%, respectively, similar with reported CR rates with CHOP-like chemotherapy (p = .6). Of the patients, 51 (81%) experienced ≥1 unplanned hospital admission; only 41 (65%) completed six cycles. The cytarabine modifications did not prevent significant toxicity. Modified hyper-CVAD/MA resulted in similar outcomes to CHOP-like chemotherapy in aggressive lymphomas and was associated with significant toxicity.

Peripheral T-Cell Lymphoma of the Oral Cavity Diagnosed in the Buccal Mucosa with Relapsed-Refractory Lesion in the Lip: a Rare Case Report

Peripheral T-cell lymphoma consists of a rare and generally aggressive non-Hodgkin lymphoma group that develops from mature T cells; its primary oral manifestations are rare. A 35-year-old Caucasian man presented with swelling, of 2 months' evolution, on the right side of the buccal mucosa, close to the tooth #16, recently treated endodontically; the swelling was painless, with numbness and anesthesia. Upon palpation, a fibrous cord in the buccal mucosa, from the region of tooth #16 to the incisor, was observed. Anatomopathologic and immunohistochemical analyses revealed peripheral T-cell non-Hodgkin lymphoma with CD3-positive markers and Ki-67 positive in 60% of the nuclei. Imaging examinations showed an enlargement of right level IB and bilateral IIA lymph nodes. The tumor was rated according to the Ann Arbor staging as IIB/E and treated with CHOP. The tumor relapsed and was refractory to treatment after 5 months, manifesting swelling in the lower right lip. The case is under follow-up.

Co-targeting aurora kinase with PD-L1 and PI3K abrogates immune checkpoint mediated proliferation in peripheral T-cell lymphoma: a novel therapeutic strategy

Peripheral T-cell non-Hodgkin lymphoma (PTCL) are heterogeneous, rare, and aggressive diseases mostly incurable with current cell cycle therapies. Aurora kinases (AKs) are key regulators of mitosis that drive PTCL proliferation. Alisertib (AK inhibitor) has a response rate ∼30% in relapsed and refractory PTCL (SWOG1108). Since PTCL are derived from CD4+/CD8+ cells, we hypothesized that Program Death Ligand-1 (PD-L1) expression is essential for uncontrolled proliferation. Combination of alisertib with PI3Kα (MLN1117) or pan-PI3K inhibition (PF-04691502) or vincristine (VCR) was highly synergistic in PTCL cells. Expression of PD-L1 relative to PD-1 is high in PTCL biopsies (∼9-fold higher) and cell lines. Combination of alisertib with pan-PI3K inhibition or VCR significantly reduced PD-L1, NF-κB expression and inhibited phosphorylation of AKT, ERK1/2 and AK with enhanced apoptosis. In a SCID PTCL xenograft mouse model, alisertib displayed high synergism with MLN1117. In a syngeneic PTCL mouse xenograft model alisertib demonstrated tumor growth inhibition (TGI) ∼30%, whilst anti-PD-L1 therapy alone was ineffective. Alisertib + anti-PD-L1 resulted in TGI >90% indicative of a synthetic lethal interaction. PF-04691502 + alisertib + anti-PD-L1 + VCR resulted in TGI 100%. Overall, mice tolerated the treatments well. Co-targeting AK, PI3K and PD-L1 is a rational and novel therapeutic strategy for PTCL.

TARGETING BCL‐2 IN ALK+ ALCL: AT THE CROSSROADS BETWEEN AUTOPHAGY AND APOPTOTIC CELL DEATH

Introduction: Our research team has long been working on anaplastic large cell lymphoma (ALCL), a peripheral T-cell non-Hodgkin lymphoma representing up to 20% of childhood lymphomas. In more than 70% of the cases, the oncogenic tyrosine-kinase NPM-ALK is responsible for the tumorigenic process. Although chemotherapeutic treatments have proven to be efficient against the disease, relapses occur in approximately 30% of cases, thus revealing the need for new therapeutic weapons such as targeted therapies. Crizotinib is a specific inhibitor of the ALK activity, currently used in phase II clinical studies; however, resistance to this drug has already been reported. Our team has previously shown that Crizotinib treatment of ALK+ ALCL was responsible for promoting a cytoprotective type autophagy, which in turn may lead to the selection of Crizotinib-resistant cells. Interestingly, we recently observed that Crizotinib inhibition of ALK activity also induces expression of Bcl-2, which is often downregulated in ALK+ ALCL. Bcl-2 is a well-known oncogene and has been firmly established as both an anti-apoptotic factor and a key autophagy regulator. Methods: We carried out several in vivo and in vitro experiments to knock down the expression of BCL2 by miR-34a overexpression. Results: We show that blocking the Crizotinib-induced expression of Bcl-2 through overexpression of miR-34a (also used in clinical trials) enhances the anti-tumorigenic effect of Crizotinib. We demonstrate that Bcl-2 blockade not only increases Crizotinib induced apoptotic cell death but also results in an intensified autophagic flux, that switches from cytoprotective type to deleterious type, thus enhancing the anti-tumorigenic effect of Crizotinib. Conclusion: Taken together, our data suggest that through Bcl-2 targeting, the Crizotinib/miR-34a combination represents a promising therapeutic alternative to current treatments and provide new insights into cross-regulations between apoptosis and autophagy in lymphomas upon targeted-therapy. Keywords: ALK; anaplastic large cell lymphoma (ALCL); BCL2.

Tenascin-C Is Highly Expressed in T-Cell Non-Hodgkin Lymphomas and Represents an Attractive Target for Radioimmunotherapy

Introduction: Tenascins are a family of large glycoproteins present in extracellular matrix, overexpressed in tumors compared to healthy tissues. Tenatumomab (ST2146) is an anti tenascin-C monoclonal antibody that is currently under development for radio immunotherapy (RIT) in tenascin-C expressing cancer. T-cell non-Hodgkin lymphomas (T-NHL) are a heterogeneous and rare group of poor prognosis malignancies lacking of standard treatments. Aim of the study was to evaluate the expression of tenascin-C in a cohort of T-NHL.Material and Methods: Under an IRB-approved protocol, 100 patients with a diagnosis of T-NHL in charge at the Hematology Unit of "Papa Giovanni XXII" Hospital were included in the study. Paraffin-embedded tumor samples were investigated using standard immunohistochemistry (IHC) for tenascin-C expression using tenatumomab antibody. Slides were assessed by two independent investigators. Staining was scored using the four different levels "no staining", "weak", "moderate" and "strong" (0-3). A grading system was used to express the proportion of involved areas in each case, as follows: 0 (0% to 25%), 1 (26% to 50%), 2 (51% to 75%), 3 (76% to 100%). Pattern of expression (stromal, vascular and/or cytoplasmic) was as well recorded. Tenascin C gene expression data were extracted from publicly available datasets. Association among variables was assessed with Chi square or Fisher exact test.Results:Of the 100 patients evaluated, 75 cases were peripheral T-NHL (PTCL) and 25 cutaneous T-NHL (CTCL). Specific diagnosis was, anaplastic large cell lymphoma (ALCL) ALK negative (n=21) or positive (n=19), PTCL-not otherwise specified (NOS, n=20), mycosis fungoides (n=13), angioimmunoblastic T-cell lymphoma (AITL, n=9), CD30+ primary cutaneous T-NHL (n=6) and other subtypes (n=12). Tenatumomab revealed the expression of tenascin-C in all the patients, with a staining that was weak, moderate and strong in 21, 51 and 28 of the cases. There was no significant different distribution among histologies (P=0.334). A high (>50%, grade 2-3) proportion of involved areas in pathologic samples were shown in half of the patients and this proportion was higher in ALCL ALK- (81%), AITL (78%) and ALCL ALK+ (58%) while was lower for PTCL NOS (30%) and CTCL (24%) (P=0.0019). A stromal pattern of expression was present in all the cases, vasculature was stained in 47 patients while in 21 tenascin-C was as well cytoplasmic. Vascular pattern was revealed in 56% of PTCL and 20% of CTCL (P=0.0018). To further evaluate the presence of tenascin C in T-NHL, gene expression datasets from published reports were retrieved and expression values of tenascin-C gene were extracted. Significant overexpression was present in T-NHL compared to normal tissues in both of the two considered datasets (Piccaluga et al., 2007 and Iqbal et al., 2010).Conclusions: Tenatumomab revealedthat tenascin-C is uniformly present in T-NHL with a high proportion of cases showing a strong and diffuse expression. Thus, tenascin-C represent an attractive target for RIT in this category of poor prognosis rare diseases. DisclosuresPetronzelli:Sigma Tau S.p.A: Employment.

Aurora Plus PI3K Inhibition Abrogates PD-L1 Induction in Peripheral T-Cell Non-Hodgkin Lymphoma

Introduction: Peripheral T-cell non-Hodgkin Lymphoma (PTCL) is heterogeneous and rare, accounting for 15% of non-Hodgkin lymphoma (NHL). PTCL is very aggressive, has a poor prognosis compared to B-NHL and novel therapeutic strategies are needed. Aurora A and B (AAK and ABK) are members of a highly conserved family of serine/threonine protein kinases that play key regulatory roles during normal and malignant mitosis. A recent study (SWOG1108, S1108) showed alisertib, a small molecular inhibitor of AAK/ABK to have a 30% response rate as a single-agent in relapsed/refractory PTCL (Barr et al. 2015, JCO). The novel mechanism of alisertib action provides a platform for synthetic lethal drug combinations. PI3Kinases are central signaling mediators which activate cell proliferation, immune regulation and lead to the activation of AAK/ABK through the mTOR pathway. MLN1117, a PI3KCa inhibitor is anti-proliferative and has anti-tumor activity in mouse models and in early phase clinical trials. The addition of MLN1117 to alisertib has the benefit of blocking the PI3K/mTOR and the MEK/ERK pathways. PD-L1 (CD274) is an immune checkpoint ligand that binds PD-1 and down-regulates the activity of active T-cells. PD-L1 expression is a mechanism of immune escape, allowing cancers to evade the immune system and represents a negative prognostic factor. Multiple receptor-mediated signaling pathways which regulate NF-κB, MAPK, PI3K/mTOR, and JAK/STAT are involved in PD-L1 induction. Using this mechanistic rationale, we investigated cellular drivers of PTCL in cell culture, a mouse xenograft model and in patient samples.We hypothesized a novel therapeutic strategy where aurora inhibition provides a synthetic lethal platform to target PI3K and PD-L1 signaling in PTCL.Methods: Immunohistochemistry (IHC) on 15 PTCL patient samples from S1108 was evaluated for Ki67, PD-1, and PD-L1 with reactive lymph node controls. Fluorescent microscopy provided quantification of PD-1, PD-L1 and Ki67. Cytokine arrays (RayBiotech) were used to evaluate cytokines that upregulate PD-L1 in S1108 samples. MTS assays were conducted with single agent alisertib, MLN1117, idelalisib and vincristine (VCR) in CRL-2396, TIB-48 and Jurkat T-NHL cell lines. Combination studies were conducted to ascertain IC50's and synergism (Chou-Talalay). A mouse CRL-2396 PTCL xenograft model was analyzed for anti-tumor activity of alisertib, alisertib + MLN1117, and alisertib + MLN1117 + VCR. The endpoints were response-to-therapy versus PD-1/PDL-1 expression by IHC and mechanisms of synergy-synthetic lethality.Results: IHC of PTCL pre-alisertib (S1108) revealed PD-1 and PD-L1 expression were low while Ki-67 was high. PD-L1:PD-1 staining ratio was increased at 8.9 fold (p=0.0037). Cytokine profiling (pre-alisertib and post-alisertib day 8, n=12) indicated IFNg (n=2 inc, n=4 dec, n=6 NC); TNFa (n=4 inc, n=4 dec, n=4 NC); IL-2 (n=4 inc, n=3 dec, n=5 NC); GMCSF (n=3 inc, n=3 dec, n=6 NC). IC50's for alisertib 42.0 nM; MLN1117 22.16 mM, idelalisib (inactive) and VCR 1.09 nM. Combination indices (CI) indicated strong synergism for alisertib + MLN1117, alisertib + VCR and alisertib + MLN1117 + VCR. The mouse PTCL revealed significant decreases in mean tumor volume between alisertib alone versus control (mean decrease 497 mm3, p=0.042), alisertib + MLN1117 (mean decrease 1288 mm3 p<0.001) and alisertib + MLN1117 + VCR (mean decrease 2817.5 mm3, p<0.001). Mouse PTCL tumors are being evaluated PD-1/PD-L1 expression and PI3K signaling in PTCL.Conclusion: PD-L1 is induced by chemokines and inactivates PI3K via SHP-2. However, PI3K activity induces PD-L1. Furthermore, alisertib activates PI3K/AKT hence targeting PI3K plus aurora (+VCR) abrogates PI3K activity and PD-L1 induction. Finally, PD-1/ PD-L1 IHC ratio may be useful in stratifying PTCL patients in prospective trials. The mechanistic interactions of aurora inhibition in the context of PI3K inhibition with PD-L1 blockade in under investigation (Figure 1). [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Non-mycosis Peripheral T-Cell non-Hodgkin Lymphoma involving the Skin

Non-mycosis Peripheral T-Cell non-Hodgkin Lymphoma involving the Skin

Novel Targeted Combination Therapies for Peripheral T-Cell Lymphoma

Introduction: New and promising evidence indicates that Aurora A and B kinases are important drivers of peripheral T-cell non-Hodgkin lymphoma (PTCL), a rare and heterogeneous disease accounting for ~15% of non-Hodgkin lymphomas (NHLs), without a clear standard of care. Auroras are a highly conserved family of oncogenic serine/threonine protein kinases that play key regulatory roles during mitosis. They are over-expressed and dysregulated in malignancy which make them very attractive therapeutic targets. We investigated the molecular, cellular, and cytokine drivers of PTCL in patients (S1108) treated with an aurora A inhibitor, alisertib (MLN8237). It is hypothesized that patient and pre-clinical models will guide the design of better strategies to target auroras in PTCL.Methods: Immunohistochemistry (IHC) on 22 PTCL patient samples (S1108) for level of expression of aurora A, aurora B, Myc, Notch-1, Bcl-2 and PI3Kd was performed. Nuclear positivity was determined for aurora A, B and Myc using Aperio’s Nuclear v9 Quantification algorithm. Expression of Bcl-2, Notch-1 and PI3Kd was quantified with Aperio’s Positive Pixel Count algorithm. The Raybiotech G2000 human cytokine array of 174 unique cytokines was analyzed using pre-/post-alisertib (day 8) therapy from 12 PTCL patient samples. MTS cellular cytotoxicity assays were conducted with single agent alisertib, PI3K inhibitor (MLN1117), mTor inhibitor (MLN0128) and vincristine (VCR) in TIB-48, CRL-2396 and Jurkat T-NHL cell lines. Combination studies were conducted with alisertib + MLN1117 or MLN0128 or VCR or triple combinations to ascertain IC50s and synergism (Chou-Talalay). A mouse PTCL xenograft model is underway to evaluate the anti-tumor activity of alisertib, MLN1117, and alistertib + MLN1117. Mechanistic studies were conducted for target and pathway inhibition.Results: As previously shown in patients from S0350, S1108 confirms aurora B is over-expressed in most patients (nuclear) versus aurora A (cytoplasmic). PI3Kd is over-expressed on the surface and/or the cytoplasm mainly within the tumor microenvironment. Myc expression is nuclear within a host-response type infiltrate in the tumor. Bcl-2 expression is confined to small T-cells, a host-response marker. Notch-1 expression was only observed in 2 cases within large tumor cells. Although level of expression of the 6 IHC markers did not correlate with alisertib activity, aurora B and PI3Kd are highly over-expressed in PTCL. Cytokine profiling revealed that pre-/post-alisertib is unique to each patient and are correlated to therapeutic response. Of note 4 of 12 patients had an elevated soluble TNF-RII, a poor prognostic marker in PTCL. IC50s for alisertib in CRL-2396, TIB-48 and Jurkat cells: 44-64 nM, MLN1117 9-14 μM, and MLN0128 36-130 nM. Combination indices (CI) indicate strong synergism for alisertib +MLN1117, MLN0128+MLN1117 and alisertib+MLN1117+VCR. These combinations lead to target inhibition and apoptosis. The PTCL xenograft mouse safety and response data will be available at the meeting.Conclusions: Aurora and PI3Kd inhibition + VCR holds promise as a combination targeted approach for patients with PTCL. IHC to stratify and cytokines to follow therapy are biomarkers to be considered in prospective trials in the treatment of PTCL patients. DisclosuresNo relevant conflicts of interest to declare.

Significance of clinical factors as prognostic indicators for patients with peripheral T-cell non-Hodgkin lymphoma: A retrospective analysis of 252 cases

The aim of this study was to retrospectively analyze the significance of different clinical factors for predicting the prognosis of patients with peripheral T-cell non-Hodgkin lymphoma (PTCL) with a median follow-up of 23 months. A total of 252 PTCL patients admitted to the First Affiliated Hospital of the School of Medicine of Zhejiang University between 2005 and 2011 were retrospectively reviewed. At a median follow-up of 23 months, the overall survival (OS) rate was 23.8%. Our results revealed that the presence of B symptoms (P<0.001), Eastern Cooperative Oncology Group (ECOG) score ≥2 (P<0.001), bone marrow involvement (BMI) (P<0.001), elevated lactate dehydrogenase (LDH) levels (P<0.001), elevated β2-MG levels (P<0.001), Ann Arbor stages III/IV (P=0.007) and International Prognostic Index (IPI) ≥3 (P=0.001) were poor prognostic factors for OS and intensive chemotherapy achieved a better OS outcome compared to the CHOP treatment. In conclusion, elevated LDH and β2-MG levels, B symptoms, Ann Arbor stages III/IV, BMI, high IPIs and high ECOG scores predict an unfavorable prognosis for PTCL patients. Compared to the conventional CHOP regimen, the intensive chemotherapy treatment may improve the prognosis of PTCL patients.

A phase 2, multicentre, single-arm, open-label study to evaluate the safety and efficacy of single-agent lenalidomide (Revlimid®) in subjects with relapsed or refractory peripheral T-cell non-Hodgkin lymphoma: The EXPECT trial

BackgroundThis multicentre, single-arm, open-label phase 2 trial investigated the efficacy and safety of lenalidomide monotherapy in patients with relapsed/refractory peripheral T-cell lymphoma (PTCL). MethodsPatients received oral lenalidomide 25mg once daily on days 1–21 of each 28-day cycle for a maximum of 24months, until disease progression or development of unacceptable adverse events (AEs). The primary end-point was efficacy; safety was evaluated as a secondary end-point. This study was registered with ClinicalTrials.gov, number NCT00655668. FindingsA total of 54 patients with PTCL were treated. The overall response rate was 22% (12 of 54), including complete response (CR) or unconfirmed CR (CRu) in 11% of patients; 31% of patients with angioimmunoblastic T-cell lymphoma (AITL) responded (CR/CRu in 15% of patients). The median progression-free survival and median response duration were 2.5 and 3.6months, respectively, in the intent-to-treat population, and 4.6 and 3.5months, respectively, in patients with AITL. Thrombocytopenia and neutropenia were the most common grade 3 or 4 haematological AEs, in 11 (20%) and 8 (15%) patients, respectively. Overall, 19 patients (35%) experienced at least 1AE leading to study dose interruption or reduction (commonly neutropenia or thrombocytopenia). Serious AEs were observed in 54% of patients and 12 patients died during the study; lymphoma progression (n=6); and acute respiratory distress syndrome, dyspnea, lung infiltration, neutropenic sepsis, pneumonia and cerebral ischaemia (n=1 each). InterpretationLenalidomide exhibited single-agent activity in heavily pretreated patients with PTCL, particularly in patients with AITL. Future development is warranted in specific histologies, such as AITL, and in combination with chemotherapy or other agents considered active in PTCL. FundingCelgene Corporation.

Peripheral T-cell lymphomas: analysis of histology, staging and response to treatment of 208 cases at a single institution

Peripheral T-cell lymphomas are characterized by a poor clinical outcome. We retrospectively analyzed 208 adults treated in our institution between 2000 and 2011. Median age at diagnosis was 55 years. Fifty-one percent had B symptoms and 51% serum elevated lactate dehydrogenase (LDH) levels. Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 0–1 in 63% and 2–4 in 37%. According to Ann Arbor classification, 16% were at stage I–II and 84% at stage III–IV. Histological subtypes were: 39% peripheral T-cell non-Hodgkin lymphoma (NHL) unspecified (PTCL-U), 19.5% anaplastic large cell lymphoma (ALCL), with 9.5% ALK+ and 10% ALK−, and 25% angioimmunoblastic lymphoma (AILT). Primary extranodal lymphoma represented 17%, and 8% were diagnosed with hemophagocytosis. Induction chemotherapy was CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) in 87% of patients. The median number of chemotherapy cycles was 2 (1–7). A complete response was obtained in 57% of the patients. Among them, 32% had an autologous stem cell transplant (ASCT) and 10% allogeneic SCT, while 38% were primary refractory. Five-year overall survival (OS) was 28.5% (22.3–36.3), and 5-year event-free survival (EFS) was 18.4% (13.4–25.3). A multivariate analysis showed that ALCL-ALK+ (p = 0.004), AILT (p < 0.01), extranodal involvement (p = 0.001), PS > 1 (p = 0.04), LDH < normal (p = 0.003) and hemophagocytosis (p = 0.001) were independent adverse factors for OS. We conclude that conventional chemotherapy with intensive treatment is not sufficient to improve the response rate. Optimal management is required.

Circulating Levels of TNF Receptor II Are Prognostic for Patients with Peripheral T-cell Non–Hodgkin Lymphoma

Peripheral T-cell non-Hodgkin lymphomas (T-NHL) represent a small but heterogeneous and clinically aggressive subset of NHLs with a poor outcome. Cytokines or their receptors might be associated with the clinical outcome of these lymphomas. Therefore, we tested whether gene variations and serum levels of soluble TNF receptor (TNFR)I (sTNFRI), sTNFRII, interleukin (IL)-10, or sIL-4R are predictive for treatment response in T-NHLs. Peripheral blood DNA from 117 patients with T-NHL treated in prospective clinical trials was subjected to genotyping analysis. Whenever possible, pretreatment sera were obtained, and circulating levels of sTNFRI, sTNFRII, IL-10, and sIL-4R were determined with a specific capture enzyme-linked immunoassay. Patients characterized by TNFRI-609GG (rs4149570) showed a trend toward better event free survival [EFS; univariate: P = 0.041; multivariate: HR, 1.76; confidence interval (CI), 0.99-3.14 with P = 0.056]. A protective role of IL-10-1087A, -824T, and -597A reported in another study was not confirmed in our cohort. Patients with circulating levels of soluble TNFRII ≥2.16 ng/mL had a 2.07-fold increased relative risk for shorter overall survival (OS; univariate: P = 0.0034; multivariate: HR, 2.07; CI, 0.92-4.70 with P = 0.081) and a 2.49-fold higher risk for shorter EFS (univariate: P = 0.00068; multivariate: HR, 2.49; CI, 1.22-5.08 with P = 0.012). Elevations of circulating levels of sTNFRI, IL-10, and sIL-4R are frequent, but the clinical response in these patients is not significantly different. Our findings suggest a critical role for TNF-TNFR signaling for the clinical outcome of patients with peripheral T-NHLs.

Abstract 3684: Targeting Aurora kinase in peripheral T-cell non-Hodgkin's lymphomas

Abstract Aurora kinases (A and B) are oncogenic serine/threonine (S/T) kinases that play central roles in the mitotic phase of the eukaryotic cell cycle. Over-expression of Auroras during dysregulated cell cycling and their aberrant activation over-rides mitotic and spindle check points leading to anueploidy in many human cancers make Auroras attractive therapeutic targets. Gene expression profiling in mantle cell lymphoma [MCL] have shown the Auroras are over-expressed and is a poor prognostic marker within the ‘proliferative’ signature. PTCL (NOS) are a heterogeneous group of rare non-Hodgkin's lymphomas (NHL) derived from activated CD4+ or CD8+ T cells. PTCL and anaplastic large cell lymphoma (ALCL) both of T-cell phenotype and ALK negative have an aggressive clinical course with an inferior event free and overall survival relative to B-cell NHL counterparts. The biological explanation for the difference is unknown. Patients with PTCL have a poor prognosis due to a very aggressive disease course coupled to a lack of effective therapies. Therefore, the development of novel and effective treatments based on biologically validated targets is urgently needed for this disease. We hypothesized and investigated that (1). Auroras are over-expressed in human PTCL-NOS, (2). Aurora ATP-site small molecule inhibitor (SMI) is effective in inhibiting cell proliferation and promoting apoptosis in cell culture and (3). Aurora SMI will be safe and effective in treating patients with relapsed aggressive T-cell NHL in early phase clinical trials. In this study, we demonstrate that both aurora A and B are highly over-expressed in PTCL patients and cell lines. MLN8237 (alisertib), an ATP-site small molecule inhibitor of Aurora A had potent activity in inhibiting phosphorylation of Aurora A and histone H3 in PTCL cell lines. Cells treated with MLN8237 exhibited endoreduplication confirming the mechanism of action of an Aurora inhibitor. Also, treatment of PTCL cell lines with MLN8237 induced apoptosis in a dose and time dependent manner (flow cytometry and PARP-cleavage) and inhibited cell proliferation with an IC50 &amp;lt; 0.1µM. Preliminary data from a phase II clinical trial using single-agent MLN8237 in patients with relapsed refractory aggressive NHL has demonstrated notable activity with 4 confirmed responses in 6 evaluable PTCL patients. Cytokine profiling on day 1 (pre-treatment) and day 8 (post-treatment) showed a profile consistent with aurora A activity. Together the data suggest inhibition of Auroras offers a promising treatment strategy for patients with aggressive T-cell NHL [Funded by the Lymphoma SPORE, P50 CAB0805501A1]. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3684. doi:1538-7445.AM2012-3684