Type Adult T-cell Leukemia/lymphoma Research Articles

ANK Therapeutic Prospects and Usefulness of PD-L1 and NK Activity as Biomarkers for Predicting Treatment Efficacy Revealed from the Treatment Course of Patients with HTLV-1-Associated Bronchioloalveolar Disease

Adult T-cell leukemia/lymphoma (ATL) is a peripheral T-cell neoplasm with poor prognosis that can present as HTLV-1associated bronchioloalveolar disease (HABA). Chemotherapy is recommended for ATL; however, it is not very effective against all types of ATL. Furthermore, there are no effective treatments for smoldering HABA-associated ATL. We present a case in which amplified natural killer cell (ANK) therapy was effective in a woman in her early 80s who was previously diagnosed with ATL-related smoldering HABA and presented with dyspnea and productive cough on exertion. The symptoms were suppressed for approximately 10 months after the first treatment, but then gradually worsened. About a year later, a second treatment was followed by mild side effects. Suppression of ATL cell proliferation by repeated doses of ANK therapy appears to be effective in this patient. The therapeutic effect was high even with long treatment intervals, and the efficacy and safety of repeated treatments have been demonstrated. ANK therapy is expected to be the mainstay of treatment ATL and HABA. ANK therapy has been reported to kill PD-L1 positive tumor cells and some solid tumors with excellent responses have many PDL1-positive tumor cells. ANK therapy is thought to be effective for ATL because there are many PD-L1-positive tumor cells. Furthermore, administration of activated NK cells may increase tumor-killing activity in those patients with reduced NK activity. While future studies are needed, PD-L1 positive rate and NK activity may be biomarkers for the effectiveness of ANK therapy.

ANK Therapeutic Prospects and Usefulness of PD-L1 and NK Activity as Biomarkers for Predicting Treatment Efficacy Revealed from the Treatment Course of Patients with HTLV-1-Associated Bronchioloalveolar Disease

Adult T-cell leukemia/lymphoma (ATL) is a peripheral T-cell neoplasm with poor prognosis that can present as HTLV-1associated bronchioloalveolar disease (HABA). Chemotherapy is recommended for ATL; however, it is not very effective against all types of ATL. Furthermore, there are no effective treatments for smoldering HABA-associated ATL. We present a case in which amplified natural killer cell (ANK) therapy was effective in a woman in her early 80s who was previously diagnosed with ATL-related smoldering HABA and presented with dyspnea and productive cough on exertion. The symptoms were suppressed for approximately 10 months after the first treatment, but then gradually worsened. About a year later, a second treatment was followed by mild side effects. Suppression of ATL cell proliferation by repeated doses of ANK therapy appears to be effective in this patient. The therapeutic effect was high even with long treatment intervals, and the efficacy and safety of repeated treatments have been demonstrated. ANK therapy is expected to be the mainstay of treatment ATL and HABA. ANK therapy has been reported to kill PD-L1 positive tumor cells and some solid tumors with excellent responses have many PDL1-positive tumor cells. ANK therapy is thought to be effective for ATL because there are many PD-L1-positive tumor cells. Furthermore, administration of activated NK cells may increase tumor-killing activity in those patients with reduced NK activity. While future studies are needed, PD-L1 positive rate and NK activity may be biomarkers for the effectiveness of ANK therapy.

Elevation of the Plasma Levels of TNF Receptor 2 in Association with Those of CD25, OX40, and IL-10 and HTLV-1 Proviral Load in Acute Adult T-Cell Leukemia.

Adult T-cell leukemia/lymphoma (ATL) cells express TNF receptor type-2 (TNFR2) on their surface and shed its soluble form (sTNFR2). We previously reported that sTNFR2 levels were highly elevated in the plasma of patients with acute ATL. To investigate whether its quantitation would be helpful for the diagnosis or prediction of the onset of acute ATL, we examined the plasma levels of sTNFR2 in a large number of specimens obtained from a cohort of ATL patients and asymptomatic human T-cell leukemia virus type 1 (HTLV-1) carriers (ACs) and compared them to those of other candidate ATL biomarkers (sCD25, sOX40, and IL-10) by enzyme-linked immunosorbent assays (ELISA) and HTLV-1 proviral loads. We observed that sTNFR2 levels were significantly elevated in acute ATL patients compared to ACs and patients with other types of ATL (chronic, smoldering, and lymphoma). Importantly, sTNFR2 levels were significantly correlated with those of sCD25, sOX40, and IL-10, as well as proviral loads. Thus, the present study confirmed that an increase in plasma sTNFR2 levels is a biomarker for the diagnosis of acute ATL. Examination of plasma sTNFR2 alone or in combination with other ATL biomarkers may be helpful for the diagnosis of acute ATL.

Trial in Progress: A Phase II Trial of Belinostat As Consolidation Therapy with Zidovudine for Adult T-Cell Leukemia-Lymphoma (ATLL)

Background: Adult T-cell leukemia-lymphoma (ATLL), a lymphoid malignancy associated with human T-cell leukemia virus type 1 (HTLV-1), is endemic in regions such as southwestern Japan, the Caribbean basin, and parts of South America, and central Africa where HTLV-1 is prevalent. Generally, ATLL cannot be cured with chemotherapy alone, and has dismal long-term outcomes. Previous clinical trials have only yielded modest results.Zidovudine (ZDV) is a synthetic nucleoside analog that inhibits reverse transcriptase and DNA polymerase resulting in inhibition of DNA replication and cell proliferation. Studies have demonstrated ZDV plus interferon (IFNα) therapy, as induction, followed by maintenance therapy, can be an efficacious first line treatment in leukemic forms of ATLL. A meta-analysis showed ZDV/IFNα therapy compared better to conventional chemotherapy for acute and chronic leukemic type ATLL in terms of overall survival. NCCN guidelines include ZDV/IFNα as a first-line therapy option for ATLL. While ZDV-IFNα can be effective in some ATLL patients, as with chemotherapy, molecular response rates are suboptimal, and patients usually relapse and succumb to their disease. Therefore, new therapeutic approaches and strategies are urgently needed to treat ATLL.Belinostat, a pan-HDAC inhibitor, obtained accelerated approval in 2015 for treatment of relapsed/refractory PTCL based on efficacy and duration of response. We hypothesize that belinostat will exert anti-neoplastic effects in ATLL cells through a variety of molecular mechanisms including activation of silenced key cellular genes and suppression of HBZ (only HTLV-1 protein consistently expressed in all ATLL tumors) and through HDAC inhibition, belinostat will reactivate HTLV-1 provirus in ATLL cells and infected T-cell reservoirs, thus eliciting an immune response against virus infected cells.Here, we describe a trial designed to evaluate safety and response of belinostat in combination with ZDV as consolidation therapy for treatment of ATLL. Correlative studies include measuring HTLV-1 reactivation in peripheral blood T-cells, assessing cytotoxic T-cell response in vivo, and investigating molecular effects of belinostat in ATLL cells in vivo.Study Design: This phase 2, single arm, open-label trial will evaluate the combination of belinostat and ZDV as consolidation therapy followed by standard ZDV-based maintenance therapy with optional IFNα-2b or pegylated interferon-alfa-2b (PEG-IFN-α-2b). The study will include up to 20 adult participants with histologically or cytologically documented ATLL, HTLV-1 infection, who have achieved and maintained at least a partial hematologic response to prior ZDV/IFNα therapy or chemotherapy. Residual ATLL in peripheral blood is required prior to enrollment. Patients must have measurable, clinically evaluable or molecular disease, with adequate end organ and bone marrow function (unless due to lymphomatous infiltration) and KPS ≥50% or ECOG performance status ≤3.The active study period includes a treatment period of up to 8 cycles (21 days each = ~6-months). Additional assessments will occur at the end of Cycle 8, Month 9, Month 12 and an end-of-treatment visit (≤ 30-days after the last dose of study treatment). Patients who achieve/maintain CR and complete 1 year of therapy will undergo follow-up assessments every 3 months for 1 year, and survival assessment every 6 months up to Year 5.ZDV will be administered in the outpatient setting as 300mg tablets orally, three times daily, starting at least 24-hours prior to the first dose of belinostat. Belinostat will be administered as 1,000 mg/m 2 IV infusion over 30 minutes on Days 1-5, every 21 days, on cycles 1- 8, followed by continuation of ZDV (+/- IFN-α) as maintenance therapy up to the end of Month 12. ZDV may be administered for a minimum 12 months from the beginning of the study.Primary objectives are to evaluate safety and determine complete molecular response rate after addition of belinostat as consolidation therapy for ATLL during ZDV-based maintenance treatment. Secondary outcomes will include evaluation of clinical response rates, investigation of whether belinostat disrupts HTLV-1 latency load in vivo, investigation of whether belinostat provokes immune or cytotoxic T-cell response in vivo and determine the impact of belinostat/ZDV (+/- IFNα) on HTLV-1 proviral load (measure of HTLV-1 infected reservoirs), in vivo. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Epidemiology, Clinical Features, and Outcome of HTLV-1 Related Adult T-Cell Leukemia-Lymphoma in a Prevalent Area in the United States

▪Introduction:Adult T-cell leukemia/lymphoma (ATLL) is an aggressive, peripheral T-cell neoplasm caused by the human T-cell leukemia virus type 1 (HTLV-1). HTLV-1 infects up to 10 million people worldwideand is most endemic in Southwestern Japan, the Caribbean basin, South America, and Western Africa. South Florida is the continental U.S. region most proximal to the Caribbean, therefore HTLV-1 associated diseases are commonly encountered in Miami. ATLL carries a dismal prognosis and is essentially incurable by conventional drugs. We describe the epidemiology, clinical features, treatment, and disease outcome of ATLL encountered at the University of Miami and affiliated hospitals over the past 3 decades. To our knowledge, this study is the largest of its kind ever conducted in the U.S.Methods:We conducted a retrospective analysis of patients (pts) diagnosed with ATLL between January 1987 and December 2016. ATLL cases were classified according to the Shimoyama criteria into acute (A), lymphomatous (L), unfavorable chronic (UC), chronic (C), and smoldering (S). Treatment approaches used as first-line therapy were: 1) chemotherapy alone; 2) combined chemotherapy with zidovudine/interferon-alpha (AZT-IFN) (concurrently or sequentially after chemotherapy); and 3) AZT-IFN alone. Treatment response was assessed according to the consensus report for ATLL published in 2009 by Tsukasaki et al . To be classified as complete response (CR), partial response (PR), and stable disease (SD), these had to persist for a period of at least 4 weeks.Results:A total of 203 pts with ATLL were identified. One hundred and ninety-five pts (L=101, A=76, UC=7, S=4, C=3, and unclassified=4) had sufficient data for analysis. Demographic characteristics are shown in Figure 1 and Table 1. Median age at diagnosis was 52 years. Female predominance was observed in aggressive ATLL pts (62% in A vs. 55% in L type, p=0.383). The great majority of pts were Afro-Caribbean (n=147, 77%) originating from Haiti (n=76, 39%) and Jamaica (n=47, 24%). Hypercalcemia was highly associated with A type (74% vs. 22% L type) (p=0.012). HIV co-infection was observed in 17 (9%) cases. The most commonly affected extranodal sites other than peripheral blood and bone marrow in all subtypes were skin 25% (n = 55), bone with lytic lesions 14% (n=27), lung 13% (n=26), liver 13% (n=23), and CNS 6% (n=11). Regimens used during the first 3 treatment attempts are summarized in Table 2. The median survival (MS) times were 4.3 months, 10 months, 67 months, and 72 months for A, L, UC, and C/S forms, with 4-year survival of 13%, 4%, 57%, and 75%, respectively (Figure 2). Among pts diagnosed between 2000 and 2016 when modern conventional therapies were available, the 4-year OS rates were 14% for A (MS 4.4 months), 6 % for L (MS 12.8 months), 67% for unfavorable chronic (MS 67 months), and 75% for C/S. First-line AZT-IFN resulted in overall response (OR) rate of 56% (CR 23%) for A (n=43) vs. 33% (CR 16.5%) for L (n=6), respectively (Table 3). The OR rates after first-line multi-agent chemotherapy alone for A vs. L were 78% (CR 39%) and 67% (CR 33%), respectively (Table 3). Progression-free survival (PFS) rates in pts with aggressive ATLL who achieved CR after AZT-IFN vs. chemotherapy were 48 months vs. 13 months, respectively (p=0.003) (Figure 3). Regarding chemotherapy regimen choice, intensive VCAP-AP-VECP (a modified version of Japanese LSG-15 VCAP-AMP-VECP) trended to yield a higher CR rate (59%, n=17) as compared to EPOCH (19%, n=26) and CHOP-based chemotherapy (35%, n=37). Two of 4 pts with L type ATLL who underwent allogeneic hematopoetic stem cell transplant (allo-HSCT) had PFS of 21 and 28 months.Conclusion:ATLL continues to have a poor outcome despite conventional therapies thus urging the development of novel approaches. Our study found higher rates of hypercalcemia and elevated LDH in A type as compared to those previously reported in Japanese pts, which suggests the Afro-Caribbean ATLL variant may present more aggressively. AZT-IFN was highly associated with a superior outcome in pts with aggressive ATLL who achieved CR with this regimen over chemotherapy alone. Altogether, our clinical experience suggests AZT-IFN is a reasonable first line option for aggressive leukemic ATLL types, and may be the best treatment option for UC type. Chemotherapy remains the preferred choice for L type ATLL, and A type when AZT-IFN is not be feasible, with consideration of allo-HSCT upfront. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Histone Deacetylase Inhibitors Abolish HBZ Protein Expression and Induce Cell Death in HTLV-1 Related Adult T-Cell Leukemia-Lymphoma

Background:Adult T-cell leukemia-lymphoma (ATL) is a malignancy with dismal prognosis caused by HTLV-1. ATL is incurable by conventional drugs. Histone deacetylase (HDAC) inhibitors (HDIs) are broadly active anti-neoplastic agents that can be cautiously exploited in the treatment of viral related lymphomas. HTLV-1 usually establishes lifelong latency in human CD4+ T-cells, which in turn propagate and persist as result of the multifaceted functions of HTLV-1 basic zipper factor (HBZ) through various signaling pathways that promote growth and proliferation, and block apoptosis and cell senescence. All ATL cells harbor at least one copy of latent intact HTLV-1 provirus in most cases, and unlike Tax, all tumors express HBZ from the negative 3‘ proviral strand via SP-1 activity. The HTLV-1 promoter is negatively regulated by HDACs at the 5‘ long terminal repeat (LTR), and by HBZ, which disrupts Tax positive interaction with the transcriptional activator p300/CBP, thus blocking viral transcription. Therefore, treatment of HTLV-1 infected cells with HDIs can induce expression of Tax protein, which is highly immunogenic, and which could promote immune-mediated clearance of ATL cells in vivo.Methods:Low-passage IL-2 dependent ATL cell lines established from patients with acute type ATL and freshly isolated ATL cells were treated with several HDIs (VPA, sodium butyrate, vorinostat, belinostat, panabinostat, and mocetinostat) at various doses and time points. Apoptosis was measured by annexin V and FACS analysis. Expression of HBZ protein, Tax, acetyl and total histone 3 subunits (H3), BIM, caspase 3, caspase 9, Jun B, c-Jun, Jun D, and Sp-1 were measured by Western blots before and after HDI treatment. HBZ and Tax mRNA expression was measured by quantitative RT-PCR. SP-1 binding to HTLV-1 specific oligonucleotide consensus sequence was measured by gel shift assay using nuclear protein extracts before and after HDI treatment.Results:HDIs sequentially increased acetylated H3 levels, blocked HBZ protein, upregulated Tax expression, stabilized BIM, and induced cleavage of pro-caspases 9 and 3 (intrinsic apoptotic pathway), resulting in apoptosis of ATL cells. HDIs tested (VPA and belinostat) blocked expression of Jun-B, which is known to be upregulated by HBZ, while no significant effects were observed on c-Jun and Jun D protein levels. HDIs tested (VPA, belinostat, and panabinostat) did not significantly alter spliced-HBZ RNA levels or affect SP-1 binding to HBZ promoter-specific oligonucleotide sequence, suggesting a post-translational mechanism may contribute to abrogation of HBZ in ATL cells.Conclusions:Our data demonstrate that HDIs target ATL cells in part by abrogating HBZ protein, which could negatively impact the longevity of ATL and HTLV-1 cells in vivo. Long-term clinical use of HDIs might be beneficial for eliminating residual ATL cells after definitive treatment. A pilot clinical trial testing belinostat-based consolidation therapy for aggressive leukemic ATL types is currently ongoing at our institution (available at Clinicaltrials.gov , NCT02737046). DisclosuresNo relevant conflicts of interest to declare.

Allogeneic Stem Cell Transplantation for Adult T-Cell Leukemia/Lymphoma-Romanian Experience.

Adult T-cell leukemia/lymphoma (ATLL) is a rare and aggressive mature T-cell malignancy caused by the human T lymphoma virus I (HTLV-I) affecting 3–5% of HTLV-1 carriers and is usually diagnosed in endemic regions. Romania is a region with high prevalence of HTLV-1 infection and ATLL and with low median age at diagnosis for aggressive types. We performed a retrospective analysis of post-transplant outcome in the first Romanian patients with ATLL receiving hematopoietic stem cell allotransplant. The study population included eight patients (three males, five females), with median age of 39.5 (range 26–57), with acute (one case) and lymphoma type (seven cases) that received peripheral stem cells (PBSC) from matched related (MRD) and unrelated donors (MUD) after reduced intensity conditioning. Graft versus host disease (GVHD) developed in six patients. Relapse occurred in four cases (50%) at a median time of 5-months post-transplant. Six patients died: four cases with disease-related deaths and two patients with GVHD-related deaths. The median survival post-transplant was 19.5 months (range 2.3–44.2 months). The post-transplant survival at 1-year was 62.5%, at 2-years 50%, and at 3-years 37.5%. In our opinion allogeneic transplant improves outcome in aggressive type ATLL.

Reduced-intensity haploidentical peripheral blood stem cell transplantation using low-dose thymoglobulin for aggressive adult T cell leukemia/lymphoma patients in non-complete remission

Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) has been accepted as a treatment option for aggressive (acute or lymphoma type) adult T cell leukemia/lymphoma (ATLL) patients with a poor prognosis, when a suitable HLA-matched donor is not available. However, haplo-HSCT carries a potential risk of treatment-related mortality including severe graft-versus-host disease (GVHD). Therefore, we conducted a prospective pilot study in order to evaluate the efficacy and safety of reduced-intensity haploidentical peripheral blood stem cell transplantation (haplo-PBSCT) with low-dose thymoglobulin (2.5 mg/kg only on day −2), fludarabine, melphalan, and total body irradiation 4 Gy for aggressive ATLL. Three consecutive acute type ATLL patients, who were ineligible for conventional myeloablative conditioning due to advanced age or comorbidities, were enrolled. One patient received pretransplant mogamulizumab therapy. All the patients were not in complete remission (CR) at the time of transplantation. Our transplantation protocol was safely carried out. CR was achieved in all the patients after transplantation. HTLV-I viral loads became undetectable after transplantation. No severe adverse events such as grade III-IV GVHD or viral/fungal diseases were observed. At a follow-up of 2 years, they were still in CR. However, T cell receptor repertoire diversities were low 1 year after transplantation in next-generation sequencing. Our results show encouraging therapeutic benefits of this pilot approach using reduced-intensity haplo-PBSCT with low-dose thymoglobulin for aggressive ATLL patients.

Cord Blood Transplantation with Non-TBI-RIC Regimen Using Fludarabine and Melphalan for Adult T-Cell Leukemia / Lymphoma

Adult T-cell leukemia/lymphoma (ATLL), which is a peripheral T-cell lymphoma related to human T-lymphotropic virus type I (HTLV-1), is known as a poor prognostic disease and its median age of onset is late 60s. Allogeneic hematopoietic stem cell transplantation is considered a treatment modality to contribute prolonging the survival in some population of patients. Although cord blood transplantation (CBT) widely practiced for hematological malignancies, a Japanese registry data suggested that 1 yr and 2 yrs overall survival (OS) after CBT in ATLL patients was only about 30% and 20%, respectively (Kato K, et al. 2014 BBMT). On the other hand, promising results were reported in the patients who were received CBT during their disease was controlled (Fukushima T, et al. 2013 IJH). Since it would be considered that CBT with non-TBI regimens, especially using reduced intensity conditioning (RIC), have a potential of engraftment failure compared to TBI regimen, it is less common conditioning regimen for CBT. Here we report a safety and an efficacy of CBT with non-TBI-RIC regimen using fludarabine (Flu) and melphalan (Mel) in 34 ATLL patients. We analyzed days from the beginning of systemic chemotherapy to transplantation, engraftment of neutrophil (EN), overall survival (OS), incidence of GVHD, non-relapse mortality (NRM) and disease-mortality (DRM), respectively. OS was defined as survival days from transplantation. OS were analyzed with logrank test. Cumulative incidence of EN and GVHD was considered with early death and NRM was considered with DRM as a competing risk. Incidence of GVHD, EN, NRM, and DRM was analyzed with Gray's method. Statistical significance defined P<0.05. Statistical analysis was carried out using the EZR. Thirty-four patients (18 male, 16 female) were consecutively undergone CBT with non-TBI-RIC regimen using Flu 125 mg/m2 and Mel 140 mg/m2 between January, 2014 and August, 2018 at our institute where is located in HTLV-1-endemic area. Twenty-eight patients used tacrolimus 0.02 mg /kg/day (TAC) and methotrexate (MTX) 5 mg/m2 / day at day 1, 3, 6 after transplantation, 5 patients TAC and mycophenolate mofetil (MMF) 750-2000 mg/day and one patient TAC alone as a GVHD prophylaxis. Median age at CBT was 61 years (44-70) and 30 patients were diagnosed as acute type ATLL whereas 4 lymphoma type. Sixteen patients were status in CR and 18 non-CR at CBT. Median duration of observation was 839.5 days (370-1890) and median time to CBT from the beginning of systemic chemotherapy was 113 days (61-416). Cumulative incidence of EN was 91.2 % and median time to EN was 20 days (14-68). OS at 2 years after transplantation (2 yr OS) was 43.9 %. 2 yr OS in CR patients was 68.2 % whereas 22.2 % in non-CR. There is no statistical significance about OS in age, gender, and incidence of GVHD. Cumulative incidence of NRM at day 100 and DRM at 1 year after CBT was 26.5 % and 26.5 %, respectively. CBT with non-TBI-RIC regimen using Flu/Mel was safe based on the result of feasible incidence of EN and NRM after CBT. Since 43.9 % of 2 yr OS was relatively high rate compared to previous report of Japanese registry data, CBT with non-TBI-RIC regimen using Flu/Mel can be a promising treatment strategy for ATLL. Figure Disclosures Nakano: Novartis: Honoraria.

Phosphorylated STAT3 expression predicts better prognosis in smoldering type of adult T-cell leukemia/lymphoma.

Adult T‐cell leukemia/lymphoma (ATLL) is a mature T‐cell neoplasm, and is divided into 2 indolent (smoldering and chronic) and 2 aggressive (acute and lymphoma) clinical subtypes. Based on previous integrated molecular analyses suggesting the importance of the JAK‐STAT pathway in ATLL, we attempted to clarify the clinicopathological significance of this pathway. Clinical and morphological findings were reviewed in 116 cases with ATLL. The nuclear localizations of phosphorylated STAT3 (pSTAT3), pSTAT5, and pSTAT6 were analyzed by immunohistochemistry. Targeted sequencing was undertaken on the portion of STAT3 encoding the Src homology 2 domain. Expression of pSTAT3 was observed in 43% (50/116) of ATLL cases, whereas pSTAT5 and pSTAT6 were largely undetected. Cases with the lymphoma type showed significantly less frequent pSTAT3 expression (8/45, 18%) than those with the other subtypes (41/66, 62%; P < .001). STAT3 mutations were detected in 36% (10/28) and 19% (12/64) of cases with the smoldering and aggressive types of ATLL, respectively. The correlation between STAT3 mutation and pSTAT3 expression was not significant (P = .07). Both univariate and multivariate analysis revealed that pSTAT3 expression was significantly associated with better overall survival and progression‐free survival in the smoldering type of ATLL, whereas STAT3 mutation was not related to a line of clinical outcome. Collectively, our data show that only the lymphoma type showed a low prevalence of tumor cells positive for pSTAT3 expression, and raises the possibility that pSTAT3 expression is a novel biomarker to predict better prognosis in the smoldering type of ATLL.

Aberrant Regional DNA Hypermethylation As a Preventive and Therapeutic Target for Adult T-Cell Leukemia-Lymphoma

Aberrant DNA methylation profiles in various types of cancer have highlighted the importance of DNA methylation in human carcinogenesis and opened the prospect of targeting aberrant DNA methylation with demethylating agents as a therapy for cancer. Adult T-cell leukemia-lymphoma (ATL) is an aggressive hematological malignancy derived from CD4 (+) T-cells transformed by human T-cell lymphotropic virus-1 (HTLV-1). Although it has been estimated that 20 million people are infected with HTLV-1 worldwide, most HTLV-1 infected individuals have no symptoms and only 3-7% of HTLV-1 positive carriers develop ATL in their life time. HTLV-1 infected cells undergo multistep leukemogenesis and there are four clinical subtypes of ATL, smoldering type, chronic type, acute type, and lymphoma type. It takes several decades to acquire aggressive phenotypes through the accumulation of genetic and epigenetic abnormalities. In this study, we aimed to elucidate the contribution of aberrant DNA methylation to ATL leukemogenesis and the anti-ATL effects of DNA demethylating agents.Since the expression profiles of CADM1 and CD7 in CD4 (+) T-cells reflect ATL disease progression, fractions of HTLV-1 infected cells and normal T-cells were isolated from ATL patients, HTLV-1 carriers, and healthy volunteers using the expression statuses of CADM1 and CD7. Comprehensive genome-wide profiling of DNA methylation was performed by quantitative array-based methylation analysis at the single-CpG-site level using the Infinium HumanMethylation450 BeadChip array. Anti-ATL effects of four DNA demethylating agents were investigated in in vitro experiments using ATL-related cell lines and a xenograft mouse model.Unsupervised hierarchical clustering analysis was first conducted using the DNA methylation profiles of 20,000 CpG probes, which were randomly picked from 470,870 probes. Global DNA hypomethylation was detected in HTLV-1 infected cells at the asymptomatic carrier stage. To identify differentially methylated positions (DMPs) that specifically reflect ATL disease status, the DNA methylation profiles of a normal cell subpopulation were compared with those of a HTLV-1 infected subpopulation. We identified 12,025 hypermethylated and 33,581 hypomethylated DMPs that were specific to the HTLV-1 infected subpopulation. Importantly, the methylation profiles of hypermethylated DMPs, but not those of hypomethylated DMPs, were different between the aggressive and indolent types of ATL and could be used to distinguish them. Therefore, we next extracted and analyzed 1,207 hypermethylated CpG sites located in TSS200 CpG islands (CGIs) in hypermethylated DMPs, since TSS200 CGIs are widely recognized to regulate gene expression in a methylation dependent manner. We found the DNA methylation profiles of 1,207 probes tended to correlate with ATL disease status.Since regional DNA hypermethylation appears to be associated with ATL disease progression, we tested the anti-leukemia activities of two novel decitabine prodrugs, OR-21 and OR-12, and compared their efficacies with those of clinically available AZA and DAC. OR-21 and OR-12 showed enhanced oral bioavailability and sustained release of decitabine and decitabine 5'-monophosphate, respectively. In ATL-related T-cell lines cultured in the presence of each DNA demethylating compound, DAC and OR-21 significantly suppressed cell growth and decreased DNA methylation at LINE-1 repeat regions, which are used as a biomarker for the monitoring of global changes in DNA methylation.To establish a xenograft mouse model, cells of the HTLV-1-transformed T-cell line, MT-2, were inoculated into the subcutaneous tissue of immunodeficient Balb/c Rag-2-/- Jak3-/- mice, which lack mature T and B lymphocytes and NK cells. A visible tumor appeared 10 days after inoculation and DAC or OR-21 was injected intraperitoneally twice a week, because they were rapidly degraded in the stomach acidic environment and could not be administered orally. The AUC-guided dosing of OR21 (3.39mg/kg) suppressed tumor growth, which was comparable with that obtained with 1.25 mg/kg DAC, while OR21 showed less hematotoxicity than DAC. DisclosuresWatanabe:OHARA Pharmaceutical Co., Ltd.: Research Funding. Ureshino:OHARA Pharmaceutical Co., Ltd.: Research Funding. Kurahashi:OHARA Pharmaceutical Co., Ltd.: Employment. Fukuda-Kurahashi:OHARA Pharmaceutical Co., Ltd.: Employment. Kimura:OHARA Pharmaceutical Co., Ltd.: Research Funding.

Absence of FLT3 mutations in Iranian adult T-cell leukemia/lymphoma patients.

Background: Adult T cell leukemia lymphoma (ATLL) is a rare disease, significantly linked to the infection by the human T-cell lymphotropic virus 1(HTLV-1). ATLL is typically preceded by decades of clinical latency during which infected cells accumulate selectable traits leading to a malignant transformation. Amongst all the HTLV-1 infected carriers only about 3-5% will develop ATLL. Despite the intensive attempt to improve the overall survival, ATLL remains one of worse prognosis among the hematologic malignancies. FMS like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutations are mutations which are frequent among leukemic patients. We aimed to investigate the frequency of FLT3 mutation status in patients with acute type of ATLL which has not been studied yet. Methods: In this case control study 38 patients with acute type of ATLL were retrospectively analyzed between February 2015 and February 2017. Forty HTLV-1 positive patients were also used as control cases. Genomic DNA was extracted according to phenolchloroform protocol and two restriction fragment length polymorphism (RFLP) PCR reactions were set up to detect FLT3/ ITD and FLT3/TKD mutations. Differences between variables were evaluated by the chi-square test and t test for categorical and continuous variables, respectively. SPSS software v. 15 was used for statistical analysis. All P values were two sided and values less than 0.05 were considered to be significant. Results: No FLT3 mutations were detected in acute type of ATLL patients. So far, not many studies have shown the frequency of FLT3 mutation in ATLL patients Conclusion: Therefore, we conclude that although FLT3 mutations are rather unusual in the acute type of ATLL patients, but other alternative mechanisms associated with ATLL remain to be further investigated. This study was a novel project regarding the analysis of FLT3 mutation in the field of ATLL research.

Cutaneous presentation of adult T-cell leukemia/lymphoma (ATLL). Single-center study on 37 patients in metropolitan France between 1996 and 2016.

Adult T-cell leukemia/lymphoma (ATLL) is a hematological malignancy associated with chronic HTLV-1 infection. To describe skin lesions in ATLL. A descriptive, retrospective study between 1996 and 2016, including all patients diagnosed with ATLL at Saint-Louis Hospital (Paris, France). Thirty-seven ATLL patients were included. Fifteen patients (41%) had a cutaneous localization of the disease, which was present from the beginning of the disease for two thirds of them. ATLL types in patients with cutaneous localization of the disease were as follows: lymphoma, n=5, chronic, n=4, smoldering, n=4, acute, n=2. Half the patients had 2 or more cutaneous manifestations. The cutaneous localizations observed were as follows: nodulotumoral (n=8), plaques (n=7), multipapular (n=6), macular (n=4), purpuric (n=2). Among the 15 patients with cutaneous localization, median overall survival was significantly shorter in the acute and lymphoma types compared to the smoldering and chronic types (8.7 months vs. 79 months, P=0.003). ATLL is a hematologic malignancy with variable expression that is diagnosed only very rarely in metropolitan France, but that should be sought in patients from countries with high HTLV-1 prevalence in the event of a chronic eruption with patches, papules, plaques and/or tumors. The chronic and smoldering types are relatively indolent, whereas the acute and lymphoma forms have a poor prognosis.

Clinical characteristics and prognosis in 12 patients with adult T cell leukemia/lymphoma confirmed by HTLV-1 provirus gene detection

目的探讨成人T细胞白血病／淋巴瘤（ATLL）患者的临床特征及预后。方法对2013年3月至2015年7月23例诊治疑似ATLL患者的外周血标本，采用PCR法和测序技术检测其基因组DNA中的1型人类T细胞白血病病毒（HTLV-1）前病毒DNA，阳性患者确诊ATLL；分析确诊患者的临床特征，并随访其生存情况。结果23例疑似患者中12例确诊为ATLL，男女比例为2∶1，中位年龄51（28~66）岁，均来自福建沿海HTLV-1小流行区。12例患者中除1例为淋巴瘤型外，余均为急性白血病型。临床特征中，ATLL细胞检出率高[81.8%（9/11），典型6例，不典型3例]，肝、脾、淋巴结肿大多见，高钙血症、LDH升高常见。ATLL细胞典型免疫表型以CD4+CD8−为主。合并HBV感染率高达54.5%。10例接受化疗，其中2例获完全缓解后接受异基因造血干细胞移植。截至随访结束日期，7例死亡，4例存活，1例失访，中位生存期2.8(0.9~10.8）个月。HTLV-1前病毒基因监测提示，1例患者在移植后HTLV-1前病毒基因转阴。结论在福建省沿海地区ATLL并不罕见，ATLL具有典型的临床特征，预后不佳。

Detection of an early adult T-cell leukemia-lymphoma clone in lymph nodes with anaplastic lymphoma kinase-negative anaplastic large cell lymphoma involvement

A 58-year-old man was admitted to our hospital with systemic lymphadenopathy and was diagnosed with anaplastic lymphoma kinase-negative anaplastic large cell lymphoma (ALCL) by lymph node biopsy. Although he was a human T-cell leukemia virus type I (HTLV-1) carrier, Southern blot analysis of the lymph node did not show monoclonal integration of HTLV-1 provirus deoxyribonucleic acid (DNA). He achieved complete remission after chemotherapy and subsequently, autologous peripheral blood stem cell transplantation (auto-PBSCT) was performed. Fifteen months after the auto-PBSCT, abnormal lymphocytes in the peripheral blood gradually increased. Southern blot analysis revealed monoclonal integration of HTLV-1 provirus DNA and monoclonal rearrangement of TRB. He was diagnosed with chronic type adult T-cell leukemia-lymphoma (ATL), which immediately progressed to the acute type. He died of tumor progression despite intensive chemotherapy. We analyzed genomic alterations of the ALCL and ATL cells using array comparative genomic hybridization. We found that the genomic alteration pattern differed between the two diseases. T-cell receptor clonality analysis using polymerase chain reaction (PCR) showed that the T-cell clone of the ATL was present in the lymph nodes with ALCL involvement, but not in peripheral blood. This finding suggests that lymph nodes can serve as a niche for ATL development.

Recent Advances in Therapeutic Approaches for Adult T-cell Leukemia/Lymphoma.

Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell lymphoma caused by human T-cell leukemia/lymphoma virus type 1 (HTLV-1). ATLL occurs in approximately 3%–5% of HTLV-1 carriers during their lifetime and follows a heterogeneous clinical course. The Shimoyama classification has been frequently used for treatment decisions in ATLL patients, and antiviral therapy has been reportedly promising, particularly in patients with indolent type ATLL; however, the prognosis continues to be dismal for patients with aggressive-type ATLL. Recent efforts to improve treatment outcomes have been focused on the development of prognostic stratification and improved dosage, timing, and combination of therapeutic modalities, such as antiviral therapy, chemotherapy, allogeneic hematopoietic stem cell transplantation, and molecular targeted therapy.

Current Clinico-Epidemiological Characteristics of Adult T-Cell Leukemia-Lymphoma (ATL) Based on the 11th Nationwide Survey in Japan

Introduction: Adult T-cell leukemia-lymphoma (ATL) is a distinct peripheral T-cell lymphomacaused by human T-lymphotropic virus type I (HTLV-1), which is endemic in Japan. Only a small percentage of HTLV-1 carriers infected through breast-feeding develop the disease. Previous nationwide surveys during 1980s-2000s in Japan provided a comprehensive view on the clinio-epidemiological profiles of ATL, including the establishment of the subtype-classification (i.e., the Shimoyama criteria: acute, lymphoma, chronic, and smoldering type) based on the diversity of the clinical features and prognosis. Treatment strategies have been developed by the subtype-classification; watchful waiting for indolent ATL, intensive chemotherapy followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) for aggressive ATL. The aim of this 11th survey is to characterize the current clinio-epidemiological features of ATL in Japan in the light of previous surveys.Methods: In 2013-14, we conducted an anonymous, cross-sectional, hospital-based survey of patients with ATL who were newly diagnosed during 2010-2011 across Japan. First, we asked 2500 hospitals with departments of hematology and dermatology to participate in this survey, and then we sent questionnaires to 128 participating hospitals to accumulate data of ATL. Skilled five hematologists reviewed the data of each questionnaire sheet, and the agreements of ATL diagnosis including the subtypes between the central review and participating hospitals were evaluated using Kappa statistics. Most of the collected data were analyzed by descriptive statistics.Results: A total of 996 ATL patients were registered; of these, 41 were eliminated because of the insufficient information for the diagnosis of ATL. Overall diagnostic agreement on subtype of ATL was substantial, with a kappa value 0.71 (standard error, 0.021); most of the disagreement was within aggressive/indolent category, acute vs. lymphoma types or acute vs. unfavorable chronic types. Among the 955 evaluable patients (M/F ratio, 1.12), 70% were diagnosed in the southwest region of Japan (Kyusyu/Okinawa) where HTLV-1 is endemic, which was consistent with the past surveys. The mean age at diagnosis was 68.3 years (median 68.8, range 24.7-100.3), which was significantly higher than 60.3 years in 1994-1995 and 57.7 years in 1986-1987. The proportion of ATL patients aged over 65 years was 79 % in this survey (whereas, 48% in the 1990-1991 survey), which indicates that the allo-HSCT is not applicable to the majority of current ATL patients in Japan. The proportion of acute, lymphoma, chronic, and smoldering types was 48, 28, 10 and 13%, respectively. The proportion of smoldering and chronic types tended to be greater than previous surveys (7% and 10% in the 1988-1997 surveys combined). The proportion of subtype by age group in this survey showed that the older in age at diagnosis are, the higher proportion of lymphoma subtype (10% in those aged younger than 40 years, 20% in those 50-59, and 31% in those 70 years or older.Discussion: This 11th survey revealed several clinio-epidemiological features of current ATL in Japan different from those in past two decades. First, a considerably increasing proportion of elderly ATL patients were diagnosed, which may be expected from a recent distribution of nationwide HTLV-1 carriers in Japan (Satake, et al, 2011). Second, there is an increasing tendency in the proportion of indolent types of ATL. This may be partly influenced by participation of the dermatology departments for the first time, because early phase of ATL localized in skin were frequently diagnosed in the dermatology department. Third, the proportion of lymphoma subtype was increased with age, which suggests that aging-related unknown mechanisms may affect the subtype distribution. More detailed analysis and subsequent surveys are planned to further evaluate clinical features and the efficacy of modern therapies on prognosis of ATL. DisclosuresIshizawa:Kyowa Kirin: Speakers Bureau; GSK: Research Funding; Takeda: Research Funding; Celgin: Speakers Bureau; Kyowa Kirin: Research Funding; Celgin: Research Funding; Janssen: Research Funding; Takeda: Speakers Bureau; Pfizer: Speakers Bureau. Ishida:Bristol-Myers Squibb: Honoraria. Ishida:Kyowa Hakko Kirin Co., LTD: Honoraria, Other: Research Funding to my institution; Bayer Pharma AG: Other: Research Funding to my institution; Celgene K.K.: Other: Research Funding to my institution. Tobinai:Gilead Sciences: Research Funding. Watanabe:Daiichi Sankyo Co., Ltd.: Research Funding.

Chronic type adult T-cell leukemia-lymphoma after autolougous stem cell transplantation for ALK-negative anaplastic large cell lymphoma

An adult male patient was admitted to our hospital with systemic lymphadenopathy. He was diagnosed as having ALK-negative anaplastic large cell lymphoma (ALCL) by lymph node biopsy. Immunohistochemical staining revealed positive reaction for CD4, CD30, CD25, TIA-1, and Granzyme B, but negative for ALK and EBER. Although anti-HTLV-1 antibody in his serum was positive, monoclonal integration of HTLV-1 provirus DNA was not detected in his lymph node by Southern blot analysis. He was treated by combination chemotherapy, and complete remission was obtained by 8 courses of CHOP therapy. Subsequently he received autologous stem cell transplantation (auto-SCT). Fifteen months after auto-SCT, abnormal lymphocytes in the peripheral blood gradually increased. Southern blot analysis of abnormal lymphocytes revealed monoclonal integration of HTLV-1 provirus DNA and monoclonal rearrangement of T-cell receptor b. The patient was therefore diagnosed as chronic type of adult T-cell leukemia-lymphoma (ATL), and immediately progressed to acute type with central nervous system involvement. He died of tumor progression regardless of intensive chemotherapy. We analyzed genomic alterations of the ALCL cells and the chronic type ATL cells using high-resolution array comparative hybridization. These results revealed that the genomic alteration pattern of ALCL was different from those of the chronic type. Chronic type ATL cells had the genetic alterations such as 1q gain and CD58 loss that were frequently observed in acute type ATL than the chronic type, suggesting that these genetic events might contribute to the transformation of this case. TCR rearrangement analyses using PCR were performed for the tumor cells of ALCL and ATL to evaluate the origin of these tumor cells. Results showed that tumor cell clone of the ATL might have already proliferated in ALCL lymph node. This finding suggests that lymph nodes can serve as a niche for ATL development.

Recent advances in the treatment of adult T-cell leukemia-lymphomas.

Recent advances in treatment for adult T-cell leukemia-lymphoma (ATL) are reviewed herein. It is currently possible to select a therapeutic strategy for ATL and predict prognosis by classification of patients by clinical subtypes and clinicopathological factors. Although the overall survival (OS) of patients with ATL has increased marginally because of advances in chemotherapy, further prolongation of survival might be difficult with conventional chemotherapy alone. Promising results have been reported for antiviral therapy using zidovudine and interferon-α, and, indeed, antiviral therapy is currently the standard treatment for patients with ATL in western countries. Remarkably, the 5-year OS rates are 100% for both the smoldering-type and chronic-type ATL. Recently, treatments for ATL have included allogeneic hematopoietic stem cell transplantation and molecular targeted therapies. Furthermore, the anti-CCR4 monoclonal antibody mogamulizumab has been shown to have marked cytotoxic effects on ATL cells, especially in the leukemic type of ATL. In the lymphoma type of ATL, the response rate may be improved by combining mogamulizumab with chemotherapy. It should be recognized that prevention of infection from carriers of human T-cell leukemia virus type-I and transfer of the virus from mother to infant are crucial issues for the eradication of ATL.

Microsatellite alterations are also present in the less aggressive types of adult T-cell leukemia-lymphoma.

BackgroundAdult T-cell leukemia/lymphoma (ATL) is a mature T-cell neoplasia etiologically linked to HTLV-1. Manifestations of ATL are diverse and different clinical types with different tissue involvement and aggressiveness have been described. The mechanisms that lead to the development of ATL clinical types have not yet been clarified. Considering that in ATL patients HTLV-1 infection generally occurs in childhood, a multistep carcinogenesis model has been proposed. Microsatellite alterations are important genetic events in cancer development and these alterations have been reported in the aggressive types of ATL. Little is known about oncogenesis of the less aggressive types.Methodology/Principal FindingsIn this study we investigated the role of the microsatellite alterations in the pathogenesis mediated by HTLV-1 in the different types of ATL. We examined the presence of microsatellite instability (MSI) and loss of heterozigosity (LOH) in matched pair samples (tumoral and normal) of 24 patients with less aggressive types (smoldering and chronic) and in aggressive types (acute and lymphoma) of ATL. Four microsatellite markers D10S190, D10S191, D1391 and DCC were analyzed. MSI was found in four patients, three smoldering and one chronic, and LOH in four patients, three smoldering and one acute. None of the smoldering patients with microsatellite alterations progressed to aggressive ATL.Conclusions/SignificanceTo our knowledge, this is the first report describing the presence of MSI and LOH in the less aggressive types of ATL. These results indicate that microsatellite alterations may participate in the development of the less aggressive types of ATL.