Reduction In Size Of Lymph Nodes Research Articles

Clinical management of Kandamaalai (Cervical Lymphadenopathy) through higher-order Siddha medicines: A case report

Abstract Cervical lymphadenopathy, characterized by the swelling of lymph nodes in the neck region, presents a complex clinical scenario with varied aetiologies. The integration of traditional medicinal systems, like Siddha, offers potential alternative therapeutic approaches. This case study deals with the management of bilateral cervical lymphadenopathy using Siddha remedies tailored for Kandamaalai. A 47-year-old female patient presented with a two-month history of cervical swelling, throat discomfort, otalgia, rhinitis, and anorexia. Diagnosis revealed bilateral cervical lymphadenopathy, akin to the Siddha concept of Kandamaalai. Treatment involved Siddha medications targeting Kandamaalai, administered without adverse effects. Subsequent improvement was clinically observed, with the resolution of symptoms and reduction in lymph node size corroborated by ultrasound (USG) findings. This case underscores the potential efficacy of Siddha therapy in treating cervical lymphadenopathy, particularly Kandamaalai. Further research, including robust clinical trials, is essential to validate these outcomes and elucidate the role of Siddha medicine in contemporary healthcare settings.

Pre-Clinical Study of Ibrutinib for the Treatment of T-Cell Lymphoma Using Magnetic Resonance Imaging (MRI) Assessment

Peripheral T cell lymphoma (PTCL) has a poor prognosis and there is a need for new treatments.The sanroque mouse bears a mutation in the E3 ubiquitin ligase, Roquin, which leads to T-cell activation and autoimmunity in homozygous animals. In heterozygous mice (Roquinsan/+) T-cell lymphomas with histological similarity to human angioimmunoblastic lymphoma (AITL), the commonest subtype of PTCL, develop in 40 to 50% of animals by 6 - 12 months of age.In order to test the feasibility of using sanroque mice for pre-clinical work we carried out MRI scans of the axillary and inguinal regions before and after receiving 200mg/kg cyclophosphamide as an intra-peritoneal injection. After 28-days the MRI scans were repeated and lymph nodes, spleens and livers collected.MRI scanning was performed on a 9.4T Agilent scanner (Agilent Technologies, Santa Claire, CA, USA) with a 310mm bore diameter and 6cm inner-diameter gradient (1000mT/m maximum gradient strength). A 4cm millipede RF coil was used for RF transmission and reception. T2-weighted images were acquired using a respiratory-gated fast spin echo (FSE) sequence with TR/TE=3000/40ms, 40x40mm field of view (256x256 matrix), 32x0.8mm slices and two signal averages.Enlarged lymph nodes were identified on the pre-treatment MRI scan and compared to the equivalent lymph node following treatment (Figure 1A). There was a mean 94% reduction in lymph node size following cyclophosphamide treatment. This demonstrated that the enlarged lymph nodes were chemosensitive and that MRI scanning could be used to monitor the lymph node size in response to treatment.Interleukin-2-inducible kinase (ITK) is expressed and has essential functions in regulating normal T-cell proliferation and differentiation. ITK is also expressed in AITL and might be a therapeutic target but there is no pre-clinical data. The small molecule BTK/ITK inhibitor, ibrutinib, is effective and well tolerated in clinical practice in some B-cell lymphomas and ibrutinib is active against mouse ITK.In order to assess the effect of ibrutinib on (Roquinsan/+) T-cell lymphoma we identified twelve mice with palpable lymph nodes. Following an MRI scan, oral treatment with ibrutinib (25mg/kg in 1% (2-Hydroxypropyl)-β-cyclodextrin (2HPBD)) or equivalent volume of vehicle (1% 2HPBD) was given daily by gavage. Five mice were treated with ibrutinib for 28 days and three for reduced time periods (7 days, 14 days and 21 days). Four mice were treated with vehicle for 28 days. Following cessation of therapy a further MRI scan was performed prior to harvesting of tissues, including liver, spleen and lymph nodes. MRI images were analysed to determine the change in volume of lymph nodes during the treatment period.Responses to ibrutinib were mixed (Figure 1B & 1C): of those that received 28 days treatment 5/8 animals showed reduction in tumour size of between 10 and 86% whilst those that received shorter durations of treatment showed reductions of 8 and 11%. 3/8 ibrutinib treated animals showed increases in tumour size of 9 and 85% (mice treated for 28 days) whilst one animal treated for 7 days showed an increase of 117%. 3/4 vehicle treated animals showed stable or increasing lymphadenopathy whilst one mouse showed spontaneous tumour regression.In order to analyze the effects of ibrutinib at the cellular level we established flow cytometry protocols to determine cellular composition. Previous reports show that the majority of cells within sanroque enlarged lymph nodes are B-cells with a minority (1 to 2%) being malignant T-cells. This is similar to the pattern observed in human Tfh lymphoma. Lymph nodes were harvested following the post-treatment MRI scan and cell suspensions produced. The proportions of CD4+, CD8+ and B220+ lymphocytes were assessed. To determine the Tfh cell population CD4 positive lymphocytes were gated and the proportion of CXCR5hiPD1hi cells assessed. We did not observe any significant differences between responding and non-responding mice (Figure 1D) or treated and untreated mice.We have developed an MRI protocol to assess the response of a T-cell lymphoma model to novel agents to facilitate pre-clinical studies. We interpret our results as showing that ibrutinib is effective as a single agent in a proportion of the spontaneous T-cell lymphomas generated in the Roquinsan/+ model of Tfh lymphoma but further work is required to understand the differences between responder and non-responder tumours. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

TIME‐TO‐RESPONSE FOR PATIENTS WITH RELAPSED/REFRACTORY AGGRESSIVE B CELL NON‐HODGKIN LYMPHOMA TREATED WITH POLATUZUMAB‐BASED THERAPY

Introduction: Knowledge of time-to-response after initiation of therapy (TTR) may influence treatment recommendations made to patients (pts) with relapsed/refractory (R/R) aggressive B cell non-Hodgkin lymphoma (aBNHL) given the potential for rapid disease growth. If reported in clinical trials, TTR is dependent upon the timing of protocol-specified imaging response assessments (IRA) and does not account for clinical response to therapy (Rc), which may precede radiographic response (Rr). Here we report TTR and other response-related outcomes in pts with R/R aBNHL treated with polatuzumab (pola). Methods: Pts analyzed were those with non-Burkitt R/R aBNHL diagnosed on most recent tissue biopsy and first treated with pola at the University of Pennsylvania from 7/2019 to 12/2020. Rc was defined as reduction in lymph node size on examination, resolution of disease-related symptoms, normalization of lactate dehydrogenase (LDH) previously >2x upper limit of normal or disease response on imaging performed for indication other than IRA. Rr was assessed per Revised Response Criteria for Malignant Lymphoma. Timing of clinical/laboratory assessments and IRA were at the discretion of the treating clinician. Data were censored on 3/1/2021. Results: Fifty pts were included in this analysis. Baseline clinicopathologic and treatment characteristics at time of pola initiation are listed in Table 1. Nineteen pts (38%) were treated with the intent to bridge to cellular therapies (CT). Median number of cycles of pola received was 3. Rc was achieved by 18 pts (36%), Rr by 16 pts (32%) and the composite outcome of Rc or Rr (overall response, [Ro]) by 24 pts (48%). IRA was not performed for 9 pts: 7 due to proceeding to planned CT (5 with Rc) and 2 due to death not attributed to aBNHL with ongoing Rc. The median TTRc, TTRr and earliest of TTRc or TTRr (TTRe) were 21 d (range 7-41 d), 64 d (range 17-137 d) and 22 d (7-67 d), respectively. Of 12 pts who achieved Rc and had subsequent IRA performed, 8 achieved Rr. Twelve pts stopped tx in remission: 7 pts due to proceeding to planned CT, 3 due to toxicity (gastrointestinal in 2 pts and neuropathy in 1 pt) and 2 pts due to choice. Excluding the 7 pts proceeding to planned CT in remission, the estimated proportion of pts with ongoing Rc and Rr at 180 d were 53% and 51%, respectively. Of characteristics listed in Table 1, non-high grade B cell histology and receipt of prior CD19-directed chimeric antigen receptor-modified T cell therapy were significantly associated with achievement of Ro; additionally, age ≤60 years, largest tumor diameter ≤7.5 cm and disease refractory to most recent prior therapy were significantly associated with shorter TTRe. Conclusions: For R/R aBHL pts treated with pola at our institution, frequently with the intention to bridge to CT, 48% achieved Rc or Rr with median TTR of 22 d. These findings may further inform use of pola in the standard-of-care and investigational settings. Keywords: Aggressive B-cell non-Hodgkin lymphoma Conflicts of interests pertinent to the abstract M. E Hughes Consultant or advisory role: AstraZeneca, Genzyme, Janssen, AbbVie, Karyopharm Research funding: Acerta S. D Nasta Consultant or advisory role: Morphosys, Merck Research funding: Roche/Genentech, Millennium/Takeda, Pharmacyclics, ATARA, Forty Seven J. N Gerson Consultant or advisory role: Pharmacyclics, Genentech, AbbVie Research funding: Loxo J. Svoboda Consultant or advisory role: Seattle Genetics, Bristol-Myers Squibb, Pharmacyclics, Imbrium Therapeutics, Genmab, Adaptive Biotechnologies, ADC Therapeutics, Atara Biotherapeutics Research funding: Celgene, Seattle Genetics, Pharmacyclics, Merck, Bristol-Myers Squibb, Incyte Educational grants: Imbrium Therapeutics E. A Chong Consultant or advisory role: Novartis, Tessa Therapeutics, Bristol-Myers Squibb, Kite/Gilead S. J Schuster Consultant or advisory role: Celgene, Nordic Nanovector, Novartis, AbbVie, Acerta, Alimera Sciences, BeiGene, Juno Therapeutics, Loxo Oncology, Tessa Therapeutics, Genetech/Roche, Research funding: Novartis, Pharmacyclics, Adaptive Biotechnologies, Merck, Genetech/Roche, Celgene, Juno Therapeutics, AbbVie, Incyte, TG Therapeutics, DTRM, S. K Barta Consultant or advisory role: Monsanto Honoraria: Atara, Seattle Genetics, Janssen, Pfizer, Acrotech Research funding: Seattle Genetics, D. J Landsburg Consultant or advisory role: Morphosys, Karyoparhm, Celgene Research funding: Takeda, Curis, Triphase Other remuneration: Karyopharm

Immunotherapeutic Targeting of ROR1-Dependent, Non-Canonical Wnt5a-Signaling By Cirmtuzumab: A First-in-Human Phase I Trial for Patients with Intractable Chronic Lymphocytic Leukemia

Background: Cirmtuzumab is a first-in-class humanized mAb specific for ROR1, an oncoembryonic antigen found on CLL and cancer stem cells of various cancers, but not on normal post-partum tissues. Work has defined that ROR1 serves as a receptor for Wnt5a, which induces non-canonical Wnt-signaling that promotes planar-cell-polarity, migration, stem-cell renewal, and proliferation. Recent studies demonstrated that Wnt5a binds to ROR1 and induces activation of RhoA and Rac1, promoting leukemia-cell migration and proliferation, respectively. By binding a functional epitope in the extracellular domain of ROR1, cirmtuzumab can block ROR1-dependent, non-canonical Wnt5a-signaling.Methods: We conducted a phase 1 trial of cirmtuzumab in patients (pts) with progressive, relapsed/refractory CLL who were not amenable to approved therapies. The primary aims of the study were to evaluate the safety and tolerability of cirmtuzumab and determine the maximum tolerated dose and/or recommended phase 2 dose. Secondary endpoints included evaluation of antibody pharmacokinetics (PK) and pharmacodynamics (PD). To address these endpoints, pts received only 4 biweekly infusions of antibody at doses ranging from 15 mcg/kg to 16 mg/kg in a standard 3+3 pt-per-cohort schema.Results: As of a planned analysis, 20 pts have received cirmtuzumab. Pts tolerated cirmtuzumab extremely well without any noted drug-related severe adverse events or dose-limiting toxicities. Anemia (7 pts), thrombocytopenia (4 pts), and neutropenia (3 pts) were the most common AEs, were primarily grade 1, and were likely due to late-stage-disease-related cytopenias.We developed an ELISA assay to measure serum levels of cirmtuzumab capable of binding to the targeted epitope of ROR1. Peak concentrations were detected within one hour after the completion of each infusion. The serum concentrations of active cirmtuzumab increased with each subsequent infusion. We detected significant levels of cirmtuzumab for at least eight weeks following the last infusion and determined that it has half-life of >24 days (d).Twenty-four hours following the 1st infusion, the leukemic cells of pts treated at doses >/= 2 mg/kg had inactivation of RhoA and Rac1, which were each observed to be activated in all cases prior to therapy. Loss of GTPase activation also was observed for CLL cells sampled at later time points.Clinically, we observed that most pts had an initial increase in the ALC without evidence of disease progression, similar to what is observed with targeted therapies that inhibit B-cell-receptor/chemokine signaling. Such a redistributive lymphocytosis (defined as an increase in the ALC of 10% or more) was observed in 5 of 9 pts who received doses </=1 mg/kg, and 9 of 11 pts who received doses >/=2mg/kg. The lymphocytosis typically peaked 24 hours after dosing (median 36% increase, range 10-76%), with a subsequent reduction to at or below baseline levels.Most pts had stable disease when assessed at the completion of treatment. Of evaluable pts, 12 had stable disease and 2 had progressive disease, both of whom received<1mg/kg per dose of cirmtuzumab. Some patients experienced reductions in lymph node size or in absolute lymphocyte count (ALC) (max 58% reduction from baseline). Strikingly, pts generally had sustained stabilization of disease after receiving just 4 infusions of cirmtuzumab and had a long progression-free survival before requiring other therapy (PFS). The median PFS was 263 d (range 112-414 d). Of note is the steep fall-off in the PFS survival curve after a period equivalent to approximately 7x the half-life of cirmtuzumab, when the plasma antibody concentration would be expected to be negligible.Conclusions: Cirmtuzumab is well-tolerated and has a long half-life, making it feasible to consider monthly dosing. We found cirmtuzumab has biologic activity in the pts treated, specifically inactivating Rho-GTPases of leukemia cells in vivo. Despite receiving limited treatment, pts had prolonged PFS. Cumulative pre-clinical and phase 1 clinical data suggest that cirmtuzumab mobilizes ROR1-expressing CLL cells, thereby preventing progression in protective niches. These results encourage phase 2 testing of cirmtuzumab administered over a longer duration, either alone and/or in combination with other targeted therapies that have anti-leukemia activity, which might be mitigated by non-canonical, ROR1-dependent Wnt5a-signaling. [Display omitted] DisclosuresJamieson:Johnson & Johnson: Research Funding; GlaxoSmithKline: Research Funding; CTI Biopharma: Research Funding. Kipps:AbbVie: Consultancy, Honoraria, Research Funding; Roche: Consultancy, Honoraria; Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding; Gilead: Consultancy, Honoraria, Speakers Bureau.

Abstract 2663: Idelalisib impacts cell growth through inhibiting translation regulatory mechanisms in mantle cell lymphoma

Abstract Idelalisib, also known as CAL-101 and GS1101, was approved in both the US and EU in 2014 to treat relapsed chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma and follicular lymphoma. In CLL, idelalisib mechanism is not yet well-defined; however, it works in part by disrupting signaling from the tumor microenvironment, including from the B-cell receptor, which contributes to the reduction in lymph node size and increase in lymphocytosis in idelalisib-treated patients. Idelalisib selectively targets PI3Kδ, the predominantly expressed PI3K class IA family member in B-cell malignancies. PI3Kα, the more well-studied PI3K isoform is known to regulate translation and we hypothesized that PI3Kδ may similarly target translation in B-cell malignancies, such as in the aggressive and hard-to-treat mantle cell lymphoma (MCL). Treatment with 0.5-5 μM idelalisib over 24-48h resulted in moderate levels of apoptosis (4-10%), and reduction of both cell number (10-20%) and cell size (15-25%) in 3 MCL cell lines (Jeko-1, Mino, Granta 519). However, the cell size reduction was not cell cycle related. Idelalisib treatment also resulted in global protein synthesis inhibition (10-75%) in MCL cell lines and primary cells as detected by leucine incorporation assay. We confirmed that PI3K/AKT pathway is impacted by idelalisib treatment, as both AKT and GSK-3β phosphorylation were blocked by the treatment. To further examine the mechanism of protein synthesis inhibition, we investigated PI3K downstream pathways that regulate translation including the mTOR pathway. We detected decreased p70S6K (T387) and S6 (S235/236) phosphorylation in MCL cell lines, which are both downstream effectors of mTOR. In addition, we observed consistent reduction of PRAS40 (T246) phosphorylation, which is a binding partner and substrate of both AKT and mTOR. Interestingly, there was a concomitant decrease in p90RSK (T359/S363) phosphorylation, a known effector of MAPK/Erk pathway. P90RSK is directly activated by Erk, and also a regulator of mTOR and S6. In contrast, downstream translation regulator 4E-BP1 phosphorylation was unchanged following idelalisib treatment. Since 4E-BP1 activation is regulated by numerous upstream factors, redundant signaling pathways may be compensating for PI3Kδ inhibition. Consistent with effects on protein translation, preliminary results indicate induction of autophagy by idelalisib, which may be a novel mechanism that has not been previously reported in MCL. Our data provided mechanism of idelalisib-mediated effects on cell growth inhibition and suggest inhibition of protein translation as a potential mechanism. Citation Format: Qingshan Yang, Lisa S. Chen, Sattva S. Neelapu, Varsha Gandhi. Idelalisib impacts cell growth through inhibiting translation regulatory mechanisms in mantle cell lymphoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2663. doi:10.1158/1538-7445.AM2015-2663

Docosahexaenoic Acid Alleviates Atopic Dermatitis in Mice by Generating T Regulatory Cells and M2 Macrophages

Han et al. (this issue) describe a novel mechanism by which docosahexaenoic acid (DHA) may suppress atopic dermatitis symptoms in mice. They find that DHA induces FoxP3 T regulatory cells in vivo, M2 macrophages drive transforming growth factor-β and IL-10 conversion of CD4 T cells to CD4 FoxP3 T regulatory cells in vitro, and DHA-treated M2 macrophages suppress atopic dermatitis in mice.

Ibrutinib Treatment of Relapsed CLL Following Allogeneic Transplantation: Sustained Disease Response and Promising Donor Immune Modulation

Abstract Background: Treatment of relapsed chronic lymphocytic leukemia (CLL) with ibrutinib results in high rates of progression-free and overall survival. Ibrutinib, an irreversible inhibitor of Bruton’s tyrosine kinase (BTK), is FDA-approved for use in relapsed CLL. Ibrutinib may also modulate donor T cell alloimmunity via inhibition of interleukin-2-inducible kinase (ITK). Here we report the effects of ibrutinib salvage therapy in 5 CLL patients who relapsed following allogeneic hematopoietic cell transplantation (allo-HCT). In addition to minimal residual disease (MRD) response measurements, we also assessed donor T cell chimerism and donor B cell immune reconstitution following ibrutinib therapy. Methods: Five patients with high-risk CLL relapsed 1-8.5 yrs following allo-HCT. Four patients had never achieved donor CD3 T cell chimerism >95% following reduced-intensity transplant. Ibrutinib 420mg daily was started 1 mo-2 yrs after clinical relapse. Four of the 5 patients remain on ibrutinib with treatment courses ranging from 3-17 mos. CLL MRD was measured by IgH high-throughput sequencing (HTS) using the ClonoSIGHTTM test (Sequenta, Inc.), which has the sensitivity to detect 1 CLL clone per million leukocytes. Lymph node (LN) size was assessed by CT scan and reported as the sum of the products of the LN diameters (SPD). Donor B cell reconstitution was determined by IgH HTS quantification of total IgH molecules and unique IgH clonotypes. Results: Lymphocytosis was observed in all 5 patients following initiation of ibrutinib treatment, consistent with previous reports. In 2 patients who received >1 yr of ibrutinib treatment, lymphocytosis peaked at 3 wks and 8 wks after initiation of treatment and slowly declined thereafter, fully resolving within 1 yr (Fig 1A). All 4 patients with pathologic lymphadenopathy prior to treatment experienced dramatic LN reduction (Fig 1B; 68% average reduction in LN size after 3 mos on ibrutinib). The longest duration of follow-up is reported for patient SPN 3975, who had a 17p deletion and received ibrutinib for 39 mos. Treatment was discontinued after CLL MRD became undetectable by ClonoSIGHT (Fig 1C). Evidence of donor T cell immune modulation included achievement of full donor CD3 chimerism after 1 yr and resolution of oral and skin chronic graft-versus-host disease (GVHD) after 6 mos. Although this patient has been off ibrutinib for >8 mos, full donor chimerism persists and CLL MRD remains undetectable (Fig 1C). Before ibrutinib treatment, donor B cells (excluding the patient’s CLL clone) accounted for 1% of PBMC (Fig 1D). Furthermore, recovering B cells have diverse, low frequency IgH clonotypes (Fig 1E). Together, our findings show rapid, sustained, and diverse immune reconstitution without CLL recurrence following ibrutinib discontinuation. Conclusions: Ibrutinib provides effective salvage therapy for CLL relapse following allo-HCT. Post-transplant CLL relapse is often extra-nodal and our experience shows ibrutinib is effective in clearing both nodal and extra-nodal disease. Here we present one patient who stopped therapy after achieving MRD negativity and maintains undetectable disease 8 mos following ibrutinib discontinuation. Ibrutinib treatment demonstrates promising donor immune modulation by promoting full donor chimerism and resolution of chronic GVHD. Our five patient experience supports using ibrutinib in relapsed CLL patients following allo-HCT. Clinical trials are needed to determine the best duration of ibrutinib therapy following post-allo-HCT relapse, chronic GVHD treatment efficacy, and the role of ibrutinib maintenance following allo-HCT. Download : Download high-res image (120KB) Download : Download full-size image Figure 1 . (A) Percent change in absolute lymphocytic count (ALC) for 2 patients who received ibrutinib treatment for >1 yr. SPN = Stanford Patient Number. (B) Percent reduction in LN size, as reported by the sum of the product of LN diameters (SPD) for 4 patients following initiation of ibrutinib. (C) CLL MRD (reported as a percentage of WBCs) and blood donor CD3 T cell levels shown for patient SPN 3975. (D) B cells (excluding the CLL clone) as percent of total PBMC for patient SPN 3975 as measured by IgH HTS. (E) Total IgH molecules and unique IgH clone counts for patient SPN 3975 at different time points (D=day) post allo-HCT. Disclosures Kong: Sequenta, Inc.: Employment, Equity Ownership. Klinger: Sequenta, Inc.: Employment, Equity Ownership. Faham: Sequenta, Inc.: Employment, Equity Ownership, Membership on an entity’s Board of Directors or advisory committees. Coutre: Pharmacyclics, Inc.: Consultancy, Research Funding. Miklos: Sequenta, Inc.: Research Funding.

Lymph Node Flow Cytometry as a Prompt Recognition of Ultra Early Onset PTLD: A Successful Case of Rituximab Treatment.

Ultra early posttransplantation lymphoproliferative disorder (PTLD) is a rare and fatal complication after hematopoietic stem cell transplantation (HSCT). Here we report, by lymph node (LN) flowcytometry, that we early recognized ultra early PTLD after an HLA-matched sibling allo-HSCT followed by a successful treatment with anti-CD20 antibody (rituximab) in a patient in progress disease for angioimmunoblastic T-cell lymphoma (AITL). The patient was conditioned with a reduced intensity conditioning (RIC) regimen. One week after transplantation, the patient developed high fever, generalized fatigue, high Epstein-Barr virus (EBV) load, and LN enlargement. An LN lymphocyte suspension and peripheral blood flowcytometry was performed to find majority of LN lymphocytes highly expressed CD20. By highly suspicious PTLD, 4 doses of rituximab (375 mg/m2 qw) were given immediately followed by reducing and withdrawing immunosuppressant reagent. PTLD was later confirmed by pathology. The patient had good response to rituximab, showing absence of fever, reduction in LN size, and no detectable EBV-DNA. Twenty months after HSCT, the patient remains well without evidence of AITL and PTLD. The current report is one of the earliest cases of PTLD after HSCT. Taken together, by LN flowcytometry as a prompt recognition, rituximab can be an effective preemptive therapy for ultra early developed PTLD.

Ibrutinib Treatment of Relapsed CLL Following Allogeneic Transplantation: Sustained Disease Response and Promising Donor Immune Modulation

Background: Treatment of relapsed chronic lymphocytic leukemia (CLL) with ibrutinib results in high rates of progression-free and overall survival. Ibrutinib, an irreversible inhibitor of Bruton’s tyrosine kinase (BTK), is FDA-approved for use in relapsed CLL. Ibrutinib may also modulate donor T cell alloimmunity via inhibition of interleukin-2-inducible kinase (ITK). Here we report the effects of ibrutinib salvage therapy in 5 CLL patients who relapsed following allogeneic hematopoietic cell transplantation (allo-HCT). In addition to minimal residual disease (MRD) response measurements, we also assessed donor T cell chimerism and donor B cell immune reconstitution following ibrutinib therapy.Methods: Five patients with high-risk CLL relapsed 1-8.5 yrs following allo-HCT. Four patients had never achieved donor CD3 T cell chimerism >95% following reduced-intensity transplant. Ibrutinib 420mg daily was started 1 mo-2 yrs after clinical relapse. Four of the 5 patients remain on ibrutinib with treatment courses ranging from 3-17 mos. CLL MRD was measured by IgH high-throughput sequencing (HTS) using the ClonoSIGHTTM test (Sequenta, Inc.), which has the sensitivity to detect 1 CLL clone per million leukocytes. Lymph node (LN) size was assessed by CT scan and reported as the sum of the products of the LN diameters (SPD). Donor B cell reconstitution was determined by IgH HTS quantification of total IgH molecules and unique IgH clonotypes.Results: Lymphocytosis was observed in all 5 patients following initiation of ibrutinib treatment, consistent with previous reports. In 2 patients who received >1 yr of ibrutinib treatment, lymphocytosis peaked at 3 wks and 8 wks after initiation of treatment and slowly declined thereafter, fully resolving within 1 yr (Fig 1A). All 4 patients with pathologic lymphadenopathy prior to treatment experienced dramatic LN reduction (Fig 1B; 68% average reduction in LN size after 3 mos on ibrutinib). The longest duration of follow-up is reported for patient SPN 3975, who had a 17p deletion and received ibrutinib for 39 mos. Treatment was discontinued after CLL MRD became undetectable by ClonoSIGHT (Fig 1C). Evidence of donor T cell immune modulation included achievement of full donor CD3 chimerism after 1 yr and resolution of oral and skin chronic graft-versus-host disease (GVHD) after 6 mos. Although this patient has been off ibrutinib for >8 mos, full donor chimerism persists and CLL MRD remains undetectable (Fig 1C). Before ibrutinib treatment, donor B cells (excluding the patient’s CLL clone) accounted for <0.2% of total PBMC as determined by IgH HTS. Following discontinuation of ibrutinib, the percentage of donor B cells increased within 6 months, and now comprises >1% of PBMC (Fig 1D). Furthermore, recovering B cells have diverse, low frequency IgH clonotypes (Fig 1E). Together, our findings show rapid, sustained, and diverse immune reconstitution without CLL recurrence following ibrutinib discontinuation.Conclusions: Ibrutinib provides effective salvage therapy for CLL relapse following allo-HCT. Post-transplant CLL relapse is often extra-nodal and our experience shows ibrutinib is effective in clearing both nodal and extra-nodal disease. Here we present one patient who stopped therapy after achieving MRD negativity and maintains undetectable disease 8 mos following ibrutinib discontinuation. Ibrutinib treatment demonstrates promising donor immune modulation by promoting full donor chimerism and resolution of chronic GVHD. Our five patient experience supports using ibrutinib in relapsed CLL patients following allo-HCT. Clinical trials are needed to determine the best duration of ibrutinib therapy following post-allo-HCT relapse, chronic GVHD treatment efficacy, and the role of ibrutinib maintenance following allo-HCT. [Display omitted] DisclosuresKong:Sequenta, Inc.: Employment, Equity Ownership. Klinger:Sequenta, Inc.: Employment, Equity Ownership. Faham:Sequenta, Inc.: Employment, Equity Ownership, Membership on an entity’s Board of Directors or advisory committees. Coutre:Pharmacyclics, Inc.: Consultancy, Research Funding. Miklos:Sequenta, Inc.: Research Funding.

A Phase I Open-Label, Multi-Dose Escalation Study of the Dual Syk/Jak Inhibitor PRT062070 (Cerdulatinib) in Patients with Relapsed/Refractory B Cell Malignancies

Introduction: Preclinical studies of the Syk-mediated B-cell receptor pathway and Jak-mediated cytokine pathways have demonstrated a potential therapeutic advantage for the dual inhibition of both Syk and Jak kinases in the treatment of B-cell malignancies. Cerdulatinib (PRT062070) was identified from a chemistry screen as a potent and selective inhibitor of Syk, Jak1, Jak3, and Tyk2, with minimal activity against Jak2. Cerdulatinib is efficacious in rodent models of B-cell lymphoma and autoimmune disease (Coffey et al., ASH 2012) and has demonstrated anti-tumor activity in genetically diverse B-cell lymphoma cell lines that is greater than that of Syk- or Jak- selective inhibitors alone (Ma et al., ASH 2013).Methods: This Phase 1 3+3 dose escalation study is evaluating cerdulatinib, given continuously on either a once daily (QD) or twice daily (BID) schedule, for relapsed/refractory chronic lymphocytic leukemia (CLL) or B-cell non-Hodgkin lymphoma (NHL). The primary objective is to determine the maximum tolerated dose (MTD) of cerdulatinib in patients with CLL or NHL. Secondary objectives are to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of cerdulatinib and to make a preliminary assessment of antitumor activity. Toxicity is graded according to the National Cancer Institute - Common Terminology Criteria for Adverse Events (NCI-CTCAE) v4. Clinical response is evaluated according to published criteria (Hallek et al., Blood 2008:111:5446-5456; Cheson et al., J. Clin. Oncol. 2012: 25:579-586). The level of inhibition of Syk and Jak is determined using a variety of whole blood assays measuring signaling via receptors for the B-cell antigen, IL2, IL4, IL6, and GM-CSF. Serum markers of tumor burden, including CCL3, CCL4, and other markers of inflammation, are also being measured.Results: As of 4 August 2014, twelve patients have been enrolled in once daily dose cohorts of 15 mg QD, 30 mg QD, and 45 mg QD. No dose-limiting toxicities have been reported. Grade ≥3 adverse events (AEs), regardless of causality, were: Grade 3 anemia (n=1), Grade 3 neutropenia (n=1), Grade 3 fatigue (n=1), Grade 3 hypotension (n=1), Grade 3 AST increased (n=1), Grade 3 hematochezia (n=1), and Grade 5 Pneumocystis pneumonia (PCP; n=1). The patient who experienced PCP pneumonia was a 76 year old male with CLL who had received prior therapy with bendamustine and rituximab.Cerdulatinib is well-absorbed with an average terminal elimination half-life at steady state of 14 hours. Selective inhibition of Syk and Jak in whole blood assays was observed post-treatment, with IC25-IC50 (Cmin to Cmax at steady-state) against these targets achieved at the 15 mg dose level, and IC50-IC80 (Cmin to Cmax at steady-state) achieved at the 30 mg and 45 mg doses. Reductions of >50% in serum markers of inflammation, as well as in CCL3 and CCL4, were noted at all dose levels post-treatment. Two patients treated at the 15 mg dose (1 CLL, 1 follicular lymphoma [FL]) remained on study for >230 and >200 days, respectively, with stable disease (SD) prior to disease progression. One patient treated at the 30 mg dose (diffuse large B-cell lymphoma [DLBCL], who did not respond to prior R-CHOP therapy), remained on study with SD for 140 days. One patient treated at the 30 mg dose (CLL) experienced a >60% decrease in peripheral lymphocyte count prior to coming off study for PCP pneumonia. Another patient treated at the 30 mg dose (CLL) experienced early lymphocytosis and a 33% reduction in lymph node size at the end of Cycle 2 and remains on study in Cycle 3. One patient treated at the 45 mg dose (FL) experienced a 40% decrease in lymph node size at the end of Cycle 4 and remains on study in Cycle 5.Conclusions: Cerdulatinib has been well tolerated in the initial cohorts of this Phase 1 study, with no dose-limiting toxicities and preliminary evidence of anti-tumor activity. Dose escalation continues and Phase 2 expansion cohorts are planned in CLL, DLBCL and FL. DisclosuresHamlin:Gilead, Spectrum, Seattle Genetics, Genentech: Consultancy; Spectrum, GSK, Jansen and Jansen/Pharmacyclics, Portola, Seattle Genetics: Research Funding. Strickland:SCRI Development Innovations: Employment. Pandey:Portola Pharmaceuticals, Inc.: Employment; Portola Pharmaceuticals, Inc.: Equity Ownership. Coffey:Portola Pharmaceuticals: Employment, Equity Ownership. Leeds:Portola Pharmaceuticals, Inc.: Employment. Levy:Portola Pharmaceuticals: Employment; University of Michigan: Patents & Royalties. Curnutte:Portola Pharmaceuticals, Inc.: Employment, Equity Ownership; Sea Lane Biotechnologies: Consultancy; 3-V Biosciences: Equity Ownership. Wagner-Johnston:Gilead: Consultancy; Gilead: Speakers Bureau; Celgene: Research Funding. Flinn:Portola Pharmaceuticals, Inc.: Research Funding.

Cardiophrenic lymph nodes in liver transplant candidates with hepatocellular carcinoma: imaging characteristics and post‐transplant outcomes

No guidelines exist for the management of cardiophrenic lymph nodes in patients with hepatocellular carcinoma (HCC) being evaluated for liver transplantation. One hundred and seventy-eight patients with HCC listed for liver transplant received both pre-transplant computed tomography (CT) and follow-up CT scans. Enlarged cardiophrenic lymph nodes on CT were characterized and followed on subsequent scans; lymph node outcomes were assigned to "reduced" and "not reduced" categories. Tumor and patient characteristics were also recorded. Seventy-one of one hundred and seventy-eight patients (39.9%) had at least one cardiophrenic lymph node larger than 8 mm in diameter on pre-transplant CT. One hundred and sixty-six total lymph nodes were characterized. Six lymph nodes (3.6%) in two patients increased in size on follow-up imaging; all six cardiophrenic lymph nodes were presumed to represent metastases. There was a statistically significant reduction in lymph node size in patients who were transplanted vs. those who were not transplanted. Furthermore, a statistically significant association was found between increasing Model for End-Stage Liver Disease score and lymph node size reduction. There were no significant differences in post-transplant survival between patients with different lymph node outcomes. In the absence of metastatic disease in other sites, these lymph nodes are probably reactive; further workup is likely not necessary.

Abstract LB-141: Potent single agent activity of Ibrutinib (PCI-32765) in patients with chronic lymphocytic leukemia (CLL): clinical and translational results from an ongoing phase II study.

Abstract Background: B-cell receptor (BCR) activation plays a pivotal role in the pathogenesis and for progression of CLL. Ibrutinib (PCI-32765), an irreversible inhibitor of Bruton's tyrosine kinase (BTK), can disrupt BCR signaling and has durable antitumor activity in CLL. We initiated a phase II single center trial to extend this experience and assess the impact of ibrutinib on tumor cells in vivo. Methods: Treatment naïve (TN) and relapsed/refractory (R/R) pts with CLL are treated with 420 mg ibrutinib daily. Pts are enrolled in 2 cohorts: 1) deletion (del) of chromosome 17p and 2) &amp;gt;65yo and treated until disease progression. Response is evaluated at 6 months (mo) and every 6 mo thereafter. 17p del was assessed by FISH cytogenetics. Spleen volume on computed tomography (CT) scans was computed using a General Electric Advanced Workstation Server. Results: With a median follow-up of 9 mo we report on the first 53 patients: for del 17p n=29; 15 TN, 14 R/R; and for &amp;gt;65yo n=24; 8 TN, 16 R/R. Estimated event free survival at 12 mo is 94%. Most adverse events were mild with non hematologic toxicities (regardless of causality) grade ≥3 in &amp;lt;13% of pts. Two deaths on study were not treatment related. At 6 mo 95% of pts (n=44 evaluable) had a nodal response (median reduction in lymph node size of 73%) and 52% of pts had a partial response (PR) by IWCLL criteria. One pt had progressive disease (presumed Richter's transformation). All pts had a decrease in splenomegaly. The median reduction of splenic volume computed from CTs was 55% (30-1716 ml). Tumor infiltration in bone marrow biopsies (n=26), decreased by a median 82% as assessed by immunohistochemistry for CD79a and the median ALC decreased from 79 k/µl (0.5-402) to 32 k/µl (0.8-167) at 6 mo for a median reduction of 62%. We evaluated the in vivo effects of ibrutinib using blood and tissue samples collected pre and during ibrutinib treatment. On treatment expression of genes known to be induced by B-cell receptor (BCR) activation (Herishanu et al 2011) was significantly reduced in CLL cells in the peripheral blood (PB) in all pts (n=15; median reduction 57%; P&amp;lt;.001). Consistent with inhibition of BCR signaling, we found concurrent reduction in PLCγ2 phosphorylation; a direct target of BTK. Patients also donated matched lymph node (LN) core biopsies pre-treatment and within the first 4 days on treatment. Ibrutinib inhibited BCR signaling in the LN (n=8, P=.004) to a similar degree as observed in the PB. Similarly, ibrutinib decreased expression of NF-κB target genes in PB and LN. In keeping with inhibition of BCR and NF-κB signaling surface markers of cellular activation such as CD38, CD69, and CD86 were significantly reduced by ibrutinib as measured by flow cytometry (P&amp;lt;.02). Finally, ibrutinib significantly reduced tumor proliferation as determined by the percentage of PB CLL cells expressing Ki67 (median reduction of 80%; P&amp;lt;.001). Conclusions: Ibrutinib as a single agent is well tolerated and highly effective in both TN and R/R pts achieving rapid disease control in blood, lymph nodes, spleen and bone marrow that is durable. Correlative studies on patient samples during ibrutinib treatment provide direct evidence for on target effects of ibrutinib in vivo demonstrating effective and sustained inhibition of BCR and NF-κB signaling in both PB and LNs. Ibrutinib deserves further investigation as targeted therapy for CLL. We thank our patients for participation and donation of blood and tissue samples. Supported by the Intramural Research Program of NIH. Citation Format: Adrian Wiestner, Sarah Herman, Rashida Mustafa, Janet Valdez, Jade Jones, Nakhle Saba, Andrew Lipsky, Diane C. Arthur, Gerald Marti, Francine Thomas, Irina Maric, Stefania Pittaluga, Xin Tian, Susan Soto, Georg Aue, Mohammed Z. Farooqui. Potent single agent activity of Ibrutinib (PCI-32765) in patients with chronic lymphocytic leukemia (CLL): clinical and translational results from an ongoing phase II study. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-141. doi:10.1158/1538-7445.AM2013-LB-141

Mapping the Targets of Dasatinib in Chronic Lymphocytic Leukemia Reveals Distinct Roles for Abl and Btk in Drug Resistance and Adhesion, and Explains Clinical Effects On Lymph Node Reduction

AbstractAbstract 3900In the lymph node (LN) microenvironment, chronic lymphocytic leukemia (CLL) cells are protected from apoptosis by upregulation of anti-apoptotic proteins. In vitro, this can be mimicked via CD40-stimulation of CLL cells, which also provides resistance to various chemotherapeutics. Novel drugs that target kinases involved in B cell signalling, including the broad spectrum kinase inhibitor dasatinib, are currently in clinical development for CLL. We have shown previously that dasatinib prevents CD40-mediated anti-apoptotic changes in CLL (Hallaert et Blood 2008). However, the kinase(s) involved remain unidentified. Here, we coupled dasatinib to an affinity matrix and pulled down its targets from CD40-stimulated CLL cells. By mass-spectrometry and Western blotting, Abl and Btk were identified as dominant targets of dasatinib. Functional analysis revealed that CD40-mediated anti-apoptotic signals and drug-resistance could be overcome both by dasatinib and the Abl inhibitor imatinib, but not by the novel Btk inhibitor PCI-32765 (ibrutinib), whereas BCR- and chemokine-controlled adhesion could be abolished by dasatinib and ibrutinib, but not by imatinib. Thus, dasatinib combines two key aspects that are clinically relevant: inhibition of Abl overrides chemoprotective survival signals, whereas inhibition of Btk impairs integrin-mediated adhesion of CLL cells in the microenvironmental niche.This combined inhibition of Abl and Btk was put to an initial test in an open-label phase 2 trial of dasatinib combined with fludarabine in twenty refractory CLL patients. As might be expected based on the in vitro data, reductions in lymph node size were observed in most patients. A LN reduction of ≥20% provided a significant improved PFS (256 days) and OS (510 days) as compared to non-responders (80 days and 158 days respectively). Details of the clinical study will be presented separately. In conclusion, in agreement with in vitro molecular studies, dasatinib seems to have clinical efficacy in heavily pretreated refractory CLL patients. Combined, these data encourage further studies on a broad-spectrum kinase inhibitor like dasatinib in combination with other classes of drugs in relapsed and refractory CLL. Disclosures:No relevant conflicts of interest to declare.

A Comparison Of Three-Drug Anti-Tuberculous Treatment And Directly Observed Treatment Short Course In The Treatment Of Tuberculous Lymphadenitis

Setting: DOTS program implemented in the management of extra pulmonary T.B. cases under RNTCP.Objective: To study the efficacy of DOTS vs. conventional three-drug antituberculous treatment in the outpatient setting and to compare patient compliance and recurrence rates.Methods: Sputum-negative patients with tuberculous lymphadenitis cases identified at OPD level in Goa Medical College (GMC). Cases randomly allocated to three-drug and DOTS regimens. Three-drug regimen cases followed up on monthly basis at GMC OPD with monthly drug collection. DOTS cases assigned to nearby health centre for drug collection and supervised therapy and followed up at two and six months of therapy at GMC OPD. Cases assessed for decrease in lymph node size and total clearance.Results: A total of 50 outpatients were enlisted in the study and randomly assigned to DOTS and three-drug groups after clinical workup and a pretreatment interview. At two month follow-up, 100% DOTS cases showed decrease in lymph node size as compared to 0% of three-drug cases. At six months follow-up, both groups showed total lymph node clearance in 100% cases. DOTS group had three defaulters (12.5%) due to migration, and could not be followed up. No recurrences or treatment failures were observed.Conclusions: DOTS therapy is shown to be equally efficacious to the conventional three-drug regimen in management of tuberculous lymphadenitis, with early reduction in lymph node size. Default rate is still high, despite availability of drugs, due to migrant population. INTRODUCTION One Fifth of the global T.B. incidence is in India, with 1.8 million new cases every year, 0.8 million of these being infective and smear positive cases. The disease incidence peaks in people belonging to the most economically productive age group of 15-60 years. Peripheral lymph node involvement is the commonest form of extra pulmonary mycobacterial tuberculosis and the cervical region is the most commonly affected site. Tuberculous cervical lymphadenitis tends to occur more often in females and presents in young adults. According to Raviglione et al, HIV is the single most important risk factor for the progression of dormant tuberculosis into clinical disease, the virus compromising the immune response. The Revised National Tuberculosis Control program was introduced in India in 1993, and expanded to cover the entire population by June 2005. The RNTCP applied the WHO recommended DOTS strategy (Directly Observed Treatment Short Course), thus shifting the responsibility for cure from the patient to the health system. A study was carried out in the Goa Medical College (GMC) – Bambolim, Goa, comparing the standard Three-drug antituberculous treatment regimen to DOTS in the management of Tuberculous Lymphadenitis on an outpatient basis. MATERIAL AND METHODS STUDY POPULATION The study was conducted in the Out Patient Department of Surgery, Goa Medical College from August 2004 – August 2006. Study subjects had to fulfill the following: PRETREATMENT INVESTIGATIONS A) CLINICAL WORKUP B) PRETREATMENT INTERVIEW: AS PER CLINICAL PROFORMA Treatment regimens: A Comparison Of Three-Drug Anti-Tuberculous Treatment And Directly Observed Treatment Short Course In The Treatment Of Tuberculous Lymphadenitis 2 of 4 Patients were allocated to two groups by random sampling numbers. Group A: Daily self administered AKT3 2 MONTHS 4 MONTHS Group B: Category III DOTS-thrice weekly administration 2 MONTHS 4 MONTHS Patients weighing > 60 kg received additional Rifampicin 150 mg. Patients weighing less than 30 kg received drugs as per body weight. LOGISTICS Patients with self administered regimen were asked to visit the GMC OPD once a month to collect the drugs to be self administered at home. They also had to follow up at the end of two months and at completion of treatment. Patients started on Category III DOTS were registered under the same and asked to follow up at the closest health centre for drug collection. For the first two months (24 doses), the patient visited the health centre thrice weekly and took antituberculous treatment under direct supervision of the DOTS provider. For the next four months (54 doses), the patient visited the DOTS centre once weekly to collect the blister pack for the weekly treatment. One separate box containing blister packed rugs was earmarked for the patient in the health centre from Day 1 of treatment to avoid treatment interruption due to drug shortage. The patient followed up in GMC OPD at two months and six months for assessment.

Phase 1 Study of Tru-016, An Anti-CD37 SMIP™ Protein in Naïve and Relapsed and/or Refractory CLL Patients

Abstract 1792 Background:CD37 is a tetraspanin protein expressed on the surface of normal and transformed B-cells across a wide range of maturational stages. TRU-016 is a novel humanized anti-CD37 protein therapeutic that has demonstrated significantly greater direct killing of CLL cells than rituximab and greater Fc-mediated cellular cytotoxicity of CLL cells than either alemtuzumab or rituximab in pre-clinical models. A recent phase 1 study in 57 relapsed and/or refractory CLL patients treated with TRU-016 found the maximum tested dose (20 mg/kg) safe and tolerable. We now report an extension of that study to better characterize the safety and activity of this agent. Methods:Patients with naïve and relapsed/refractory CLL, adequate organ function and absolute neutrophil count >500/μL were eligible. Patients received 10, 20, or 30 mg/kg of TRU-016 administered IV once a week for 8 doses followed by 4 monthly doses. Patients treated in the dose escalation phase of the study were eligible for consideration as “roll-over” patients to be retreated in this expanded cohort study. Responses were determined using the 1996 NCI criteria. Results:26 patients (7 naïve, 16 relapsed/refractory, and 3 roll-over CLL) received TRU-016 in the expanded cohort with 12 patients in active follow up at the time of abstract submission. Patient characteristics: median age 69.5 yrs (range, 39–75), median prior regimens 2 (1–11), refractory to anti-CD20 therapy 33% (4/12), refractory to last regimen 35% (6/17) and bulky nodes ≥5 cm 50% (11/22).There were 3 subjects with dose limiting toxicities; none occurred more than once in a dose cohort. A maximum tolerated dose was not identified. The most frequent adverse events were neutropenia, chills, diarrhea, and fatigue at 21% each and thrombocytopenia, nausea, back pain, cough, and headache at 17% each. The most frequent Grade 3 or 4 adverse events were: infection in 4 patients, neutropenia in 3 patients and febrile neutropenia in 2 patients; 3 of the infections were in patients with G3/4 neutropenia or febrile neutropenia. There were 9 serious adverse events reported by 4 patients, with 2 patients having events considered possibly related to TRU-016 (febrile neutropenia in one patient; pneumonia, atrial fibrillation and diarrhea in a second).Lymphocyte reduction of ≥50% was observed in 81% (17/21) of naïve and relapse/refractory CLL and 33% (1/3) of roll-over CLL patients. Lymph node reduction of ≥50% by CT scan measurements was seen in 46% (6/13).The ORR was 86% (6/7 PR) in naive CLL and 17% (3/17 PR) in relapsed/refractory CLL. Response in relapsed CLL patients was limited to those with 1–2 prior treatments, 33% (3/9 PR), as was previously observed in the dose escalation phase of the study. Conclusions:TRU-016 treatment has a favorable safety profile and the MTD has not been reached. Clinical activity has been observed with a reduction in lymphocyte count and by a reduction in lymph node size by CT scans. The greatest response was seen in naïve CLL patients. Given the single-agent clinical activity of TRU-016 and synergistic or additive effect of TRU-016 with multiple agents in pre-clinical models, a combination trial of TRU-016 with bendamustine has been initiated in relapsed CLL patients. Updated results from ongoing patient follow-up will be presented at the meeting. Disclosures:Gopal:Millenium:. Stromatt:Emergent Product Development Seattle, LLC, Seattle, WA: Employment.

Phase 1 Study of TRU-016, An Anti-CD37 SMIP™ Protein in Relapsed and/or Refractory NHL Patients

Abstract 1636 Background:CD37 is a tetraspanin protein expressed on the surface of normal and transformed B-cells across a wide range of maturational stages. TRU-016 is a novel humanized anti-CD37 protein therapeutic that has demonstrated significantly greater direct killing of CLL cells than rituximab and greater Fc mediated cellular cytotoxicity of CLL cells than either alemtuzumab or rituximab in pre-clinical models. Preclinical in vitro and in vivo models of NHL have demonstrated significant activity of TRU-016 against multiple cell lines. A recent phase 1 study in 57 relapsed and/or refractory CLL patients treated with TRU-016 identified the maximum tested dose (20 mg/kg) as safe and tolerable. We now report an extension of that study in patients with NHL. Methods:Patients with relapsed/refractory follicular NHL (FL), mantle cell (MCL), or Waldenström’s (WM), adequate organ function, ECOG ≤2, and absolute neutrophil count >500/μL were eligible. Patients received 20 mg/kg of TRU-016 administered IV once a week for 8 doses followed by 4 monthly doses. Responses were determined using standard disease specific criteria. Results:16 patients (8 FL; 4 MCL; and 4 WM) received TRU-016 in the expanded cohort with 4 patients in follow up at the time of abstract submission. Patient characteristics: median age 63 yrs (range, 41–81), median prior regimens 4 (1–7), refractory to last regimen 56% (9/16), refractory to anti-CD20 therapy 53% (8/15), bulky nodes ≥5 cm 57% (8/14), prior autologous stem cell transplant 13% (2/16). The most frequent adverse events were neutropenia 44% (7/16), fatigue 38% (6/16) and diarrhea, nausea and thrombocytopenia, at 25% (4/16) each. The most frequent Grade 3/4 adverse events were neutropenia 38% (6/16) and thrombocytopenia 13% (2/16); there were no Grade 3/4 infections. There were 2 serious adverse events reported by 2 patients, both were considered unrelated to TRU-016 by the investigators (a death due to an anaphylactic reaction to CT contrast and Grade 2 hypotension in another patient). Lymphocyte reduction of ≥50% was observed in 25% (4/16) of patients. Lymph node reduction of ≥50% by CT scan measurements was seen in 18% (2/11). One FL NHL patient had a PR, 6 had SD and 1 had PD. Two MCL patients had SD and 2 had PD. One WM patient had a Minor Response, 2 had SD and 1 had PD. Conclusions:TRU-016 treatment has a favorable safety profile. Clinical activity was observed in this small cohort of highly refractory and heavily pretreated heterogeneous group of B-cell NHL patients including a reduction in lymphocyte count, reduction in lymph node size by CT scans and one PR. The single-agent clinical activity of TRU-016, and the synergistic or additive effect of TRU-016 with multiple agents in pre-clinical models warrants further clinical investigation in NHL. A combination trial of TRU-016 with bendamustine and rituximab has been initiated in relapsed indolent B-cell NHL patients. Updated results from ongoing patient follow-up will be presented at the meeting. Disclosures:Stromatt:Emergent Product Development Seattle, LLC, Seattle, WA: Employment. Gopal:Abbott: Research Funding.

Results of a phase I study of DTS-201, a peptidic prodrug of doxorubicin, in patients with solid tumors

2547 Background: DTS-201 is a promising prodrug of doxorubicin (dox) designed to preferentially deliver the parent compound to tumor cells and to limit cardiotoxicity. Based on animal studies showing that DTS-201 was markedly safer and more active than conventional dox, a phase I trial was conducted to determine safety, pharmacokinetics and the recommended dose (RD) for phase II studies. Methods: DTS-201 was given as 1-hour infusion every 3 weeks. Four dose levels were tested: 80, 160, 250 and 400 mg/m2 equivalent to 45 to 225 mg dox/m2. Toxicity was evaluated according to CTCAE v3.0 with specific attention to cardiotoxicity assessed by troponin I, echocardiography or cardio MUGA scan and 12-lead ECG. Results: Nineteen cancer patients (pts) with solid tumors (age range: 30–72 yrs) received DTS-201. Tolerance was good at 80 and 160 mg/m2. Three dose limiting toxicities (DLTs) were observed at cycle 1, one at 250 mg/m2 (grade 3 diarrhea) and two at 400 mg/m2 (one grade 3 vomiting and one grade 4 neutropenia = 5 days). Myelosuppression was the most common toxicity with 5 of the 6 pts treated at 400 mg/m2 experiencing transient asymptomatic grade 3–4 neutropenia on day 15 that spontaneously resolved. Other adverse reactions included mild to moderate asthenia, alopecia, anorexia and nausea. Neither cardiotoxicity or dox unrelated toxicities were observed. Disease stabilization for more than 4 cycles was observed in three pts with prostate cancer, pleural mesothelioma or bronchoalveolar carcinoma at 250 and 400 mg/m2. The pt with prostate cancer treated at 250 mg/m2 experienced a 60% decrease in serum PSA and a 23% reduction in lymph node size. The plasma AUCs and Cmax for DTS-201 and dox increased linearly with dose. At 400 mg/m2, the AUC of dox was within the range of values observed in pts receiving 60 mg/m2 of conventional dox. However the Cmax of dox, observed at 1 to 1.5 hours following DTS-201 administration, was 20 to 25 times lower. Conclusion: DTS-201 was well tolerated up to 400 mg/m2, corresponding to 3.750-fold the standard dose of dox. This dose, with no evidence of cardiac toxicity, was proposed to be the RD for future phase II studies. Six additional pts will be treated at that dose level to better characterize safety. No significant financial relationships to disclose.

Kikuchi–Fujimoto disease: a rare but important cause of fever and lymphadenopathy in pregnant women

We report a case of Kikuchi-Fujimoto disease (KFD) in a 28-year-old pregnant woman with prolonged fever and generalized lymphadenopathy. We evaluated the patient for etiology of the fever and adenopathy, which were unresponsive to antibiotic therapy. Cervical lymph node histology showed KFD. Currently, there is scant data available regarding the course and treatment of KFD during pregnancy. We administered steroid therapy (prednisone 1 mg/kg/day) to control severe systemic and constitutional symptoms. We observed a reduction in lymph node size as well as abatement of fever and other constitutional symptoms. The patient carried the fetus to full term with no apparent adverse effect. Our experience showed that steroid therapy may be used effectively to control KFD-related symptoms after the first 16 weeks without terminating the pregnancy.

Inhibition of leukemic cell proliferation by factor(s) released from irradiated lymphocytes of B-chronic lymphocytic leukemia patients.

An attempt was made to clarify the mechanism by which splenic irradiation in patients with B-chronic lymphocytic leukemia (B-CLL) can induce a reduction in lymph node size. For this purpose peripheral blood lymphocytes from B-CLL patients were exposed to cobalt irradiation and were cultured for 1-8 days. The effect of the supernatants on the proliferation capacity of normal and malignant human cells was examined. A suppression of phytohemagglutinin (PHA)-induced proliferation of autologous and heterologous B-CLL lymphocytes was observed, whereas there was no effect on the proliferation of lymphocytes obtained from healthy volunteers. In addition, supernatants of irradiated B-CLL lymphocytes inhibited thymidine incorporation into blasts derived from patients with acute leukemia and the lymphoblastoid cell line Daudi, but they did not exert any effect on normal cells obtained from human embryonic liver. These results suggest the secretion of some factor(s) by irradiated B-CLL lymphocytes, which may inhibit the proliferation of malignant cells but has no effect on normal cells.

Lymphadenopathy in chronic active hepatitis: CT observations

CT scans were obtained in 17 patients who had biopsy-proved chronic active hepatitis in order to evaluate deteriorating liver function and clinical status. Lymphadenopathy in the porta hepatis and/or retroperitoneum was found in 11 patients (65%), and this was the only CT indication of significant hepatic disease in six patients (35%). In three of five patients who subsequently underwent immunosuppressive therapy, serial biopsy, and CT scanning, clinical and histologic improvement in the condition of the liver were accompanied by a reduction in lymph-node size on CT. These findings suggest that abdominal adenopathy is a frequent CT finding in patients who have chronic active hepatitis and might be a useful marker in monitoring immunotherapy.