Bastian von Tresckow

Depletion of cellular cholesterol and lipid rafts increases shedding of CD30.

CD30, a lymphoid activation marker, is shed into the cell environment after endoproteolytic cleavage of its ectodomain. Soluble (s)CD30 is able to suppress the Th1-type immune response. Because high serum levels of sCD30 and cholesterol-lowering drugs seem to be beneficial in some Th1-type autoimmune diseases, we focused on a link between CD30 shedding and the amount of cellular cholesterol. Cholesterol depletion of human Hodgkin lymphoma- and non-Hodgkin lymphoma-derived cell lines by methyl-β-cyclodextrin led to a down-regulation of membrane-bound CD30 and increased release of sCD30. Additionally, the cholesterol-interfering drugs lovastatin, cholesterol oxidase, and filipin increased CD30 shedding. Both the down-regulation of membrane-anchored CD30 and the release of sCD30 were dependent on metalloproteinases. Using specific inhibitors, we detected TNF-α converting enzyme (TACE) as the leading enzyme responsible for cholesterol-dependent CD30 shedding. A Triton X-100-based method for lipid raft isolation revealed that CD30 was partially present in lipid rafts, whereas TACE was localized in the nonraft fractions. Disintegration of lipid rafts by cholesterol depletion might therefore lead to dynamic interactions of CD30 with TACE, resulting in enhanced shedding of CD30. Our results suggest a possible role of cholesterol-dependent shedding of CD30 in the pathogenesis of immune diseases.

Phase 2 study of rituximab in newly diagnosed stage IA nodular lymphocyte-predominant Hodgkin lymphoma: a report from the German Hodgkin Study Group

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) accounts for ∼ 5% of Hodgkin lymphoma cases. The disease is characterized by a strong CD20 expression on the malignant cells and a more indolent clinical course compared with classic HL. Anti-CD20 antibody treatment has shown clinical activity in relapsed NLPHL. In this phase 2 trial, we investigated rituximab in newly diagnosed stage IA NLPHL patients. Four weekly applications at 375 mg/m(2) were given. Among the 28 evaluable patients, overall response rate was 100%, 24 patients (85.7%) achieved complete remission, and 4 (14.3%) achieved partial remission. At a median follow-up of 43 months, overall survival was 100%; progression-free survival at 12, 24, and 36 months was 96.4%, 85.3%, and 81.4%, respectively. No grade 3 or 4 toxicity was observed. Although treatment results with rituximab appear inferior compared with radiotherapy and combined-modality approaches in early-stage patients, investigation of anti-CD20 antibody-based combinations in NLPHL is warranted. This study was registered at www.clinicaltrials.gov as #NCT00346684.

Omission of dacarbazine or bleomycin, or both, from the ABVD regimen in treatment of early-stage favourable Hodgkin's lymphoma (GHSG HD13): an open-label, randomised, non-inferiority trial

BACKGROUNDnThe role of bleomycin and dacarbazine in the ABVD regimen (ie, doxorubicin, bleomycin, vinblastine, and dacarbazine) has been questioned, especially for treatment of early-stage favourable Hodgkins lymphoma, because of the drugs toxicity. We aimed to investigate whether omission of either bleomycin or dacarbazine, or both, from ABVD reduced the efficacy of this regimen in treatment of Hodgkins lymphoma.nnnMETHODSnIn this open-label, randomised, multicentre trial (HD13) we compared two cycles of ABVD with two cycles of the reduced-intensity regimen variants ABV (doxorubicin, bleomycin, and vinblastine), AVD (doxorubicin, vinblastine, and dacarbazine), and AV (doxorubicin and vinblastine), in patients with newly diagnosed, histologically proven, classic or nodular, lymphocyte predominant Hodgkins lymphoma. In each treatment group, 30 Gy involved-field radiotherapy (IFRT) was given after both cycles of chemotherapy were completed. From Jan 28, 2003, patients were centrally randomly assigned (1:1:1:1) with a minimisation method to the four groups. Because of high event rates, assignment to the AV and ABV groups stopped early, on Sept 30, 2005, and Feb 10, 2006; assignment to ABVD and AVD continued (1:1) until Sept 30, 2009. Our primary objective was to show non-inferiority of the experimental variants compared with ABVD in terms of freedom from treatment failure (FFTF), by excluding a difference of 6% after 5 years corresponding to a hazard ratio (HR) of 1.72, via a 95% CI. Analyses reported here include qualified patients only, and between-group comparisons include only patients recruited during the same period. The trial was registered, number ISRCTN63474366.nnnFINDINGSnOf 1502 qualified patients, 566, 198, 571, and 167 were randomly assigned to receive ABVD, ABV, AVD, or AV, respectively. 5 year FFTF was 93.1%, 81.4%, 89.2%, and 77.1% with ABVD, ABV, AVD, and AV, respectively. Compared with ABVD, inferiority of the dacarbazine-deleted variants was detected with 5 year differences of -11.5% (95% CI -18.3 to -4.7; HR 2.06 [1.21 to 3.52]) for ABV and -15.2% (-23.0 to -7.4; HR 2.57 [1.51 to 4.40]) for AV. Non-inferiority of AVD compared with ABVD could also not be detected (5 year difference -3.9%, -7.7 to -0·1; HR 1.50, 1.00 to 2.26). 178 (33%) of 544 patients given ABVD had WHO grade III or IV toxicity, compared with 53 (28%) of 187 given ABV, 142 (26%) of 539 given AVD, and 40 (26%) of 151 given AV. Leucopenia was the most common event, and highest in the groups given bleomycin.nnnINTERPRETATIONnDacarbazine cannot be omitted from ABVD without a substantial loss of efficacy. With respect to our predefined non-inferiority margin, bleomycin cannot be safely omitted either, and the standard of care for patients with early-stage favourable Hodgkins lymphoma should remain ABVD followed by IFRT.nnnFUNDINGnDeutsche Krebshilfe and Swiss State Secretariat for Education and Research.

ADAM10 Inhibition of Human CD30 Shedding Increases Specificity of Targeted Immunotherapy In vitro

CD30 is a transmembrane protein selectively overexpressed on many human lymphoma cells and therefore an interesting target for antibody-based immunotherapy. However, binding of therapeutic antibodies stimulates a juxtamembrane cleavage of CD30 leading to a loss of target antigen and an enhanced release of the soluble ectodomain of CD30 (sCD30). Here, we show that sCD30 binds to CD30 ligand (CD153)-expressing non-target cells. Because antibodies bind to sCD30, this results in unwanted antibody binding to these cells via sCD30 bridging. To overcome shedding-dependent damage of normal cells in CD30-specific immunotherapy, we analyzed the mechanism involved in the release. Shedding of CD30 can be enhanced by protein kinase C (PKC) activation, implicating the disintegrin metalloproteinase ADAM17 but not free cytoplasmic calcium. However, antibody-induced CD30 shedding is calcium dependent and PKC independent. This shedding involved the related metalloproteinase ADAM10 as shown by the use of the preferential ADAM10 inhibitor GI254023X and by an ADAM10-deficient cell line generated from embryonically lethal ADAM10(-/-) mouse. In coculture experiments, the antibody-induced transfer of sCD30 from the human Hodgkins lymphoma cell line L540 to the CD30-negative but CD153-expressing human mast cell line HMC-1 was inhibited by GI254023X. These findings suggest that selective metalloproteinase inhibitors blocking antibody-induced shedding of target antigens could be of therapeutic value to increase the specificity and reduce side effects of immunotherapy with monoclonal antibodies.

Heat Shock Protein 90 Inhibitor BIIB021 (CNF2024) Depletes NF-κB and Sensitizes Hodgkin's Lymphoma Cells for Natural Killer Cell–Mediated Cytotoxicity

Purpose: In Hodgkins lymphoma, constitutive activation of NF-κB promotes tumor cell survival and proliferation. The molecular chaperone heat shock protein 90 (HSP90) has immune regulatory activity and supports the activation of NF-κB in Hodgkins lymphoma cells. Experimental Design: We analyzed the effect of HSP90 inhibition on viability and NF-κB activity in Hodgkins lymphoma cells and the consequences for their recognition and killing through natural killer (NK) cells. Results: The novel orally administrable HSP90 inhibitor BIIB021 (CNF2024) inhibited Hodgkins lymphoma cell viability at low nanomolar concentrations in synergy with doxorubicin and gemcitabine. Annexin V/7-aminoactinomycin D binding assay revealed that BIIB021 selectively induced cell death in Hodgkins lymphoma cells but not in lymphocytes from healthy individuals. We observed that BIIB021 inhibited the constitutive activity of NF-κB and this was independent of IκB mutations. Furthermore, we analyzed the effect of HSP90 inhibition on NK cell–mediated cytotoxicity. BIIB021 induced the expression of ligands for the activating NK cell receptor NKG2D on Hodgkins lymphoma cells resulting in an increased susceptibility to NK cell–mediated killing. In a xenograft model of Hodgkins lymphoma, HSP90 inhibition significantly delayed tumor growth. Conclusions: HSP90 inhibition has direct antitumor activity in Hodgkins lymphoma in vitro and in vivo. Moreover, HSP90 inhibition may sensitize Hodgkins lymphoma cells for NK cell–mediated killing via up-regulation of ligands engaging activating NK cell receptors. (Clin Cancer Res 2009;15(16):5108–16)

The ectodomain shedding of CD30 is specifically regulated by peptide motifs in its cysteine-rich domains 2 and 5

Tumor necrosis factor (TNF)‐α converting enzyme (TACE) is responsible for the ectodomain release of various membrane proteins by proteolytic cleavage in close proximity to the cell membrane. Despite the wide spectrum of possible substrates, selective cleavage can be achieved by substrate cross‐linking. To explore the underlying mechanism, we studied the TACE‐ mediated shedding of CD30. Whereas the constitutive release of the soluble ectodomain of CD30 (sCD30) from the lymphoma cell line Karpas 299 was enhanced by most anti‐CD30 antibodies, it was inhibited by antibodies Ber‐H2 and Ki‐4. On the basis of the recognized epitopes, shedding seemed to depend on the availability of the cysteine‐rich domains (CRD) 2 and 5 of the CD30 ectodomain. CRD2 and 5 have almost identical amino acid sequences and are localized distant from the TACE‐targeted cleavage site. Soluble CD30, the product of this enzyme reaction, did not inhibit, but on the contrary, it stimulated CD30 shedding in a CRD2/5‐ dependent manner. This process could also be induced by CRD2/5‐derived peptides but not by a CRD1‐derived control peptide. This example of a product‐activation was CD30 selective since other TACE substrates such as TNFR1 or TNF‐α were not affected. These data suggest that CD30 shedding is stimulated by an elevated local availability of CRD2 or 5, possibly by forming a docking station for the releasing enzyme through substrate aggregation.

Prognostic relevance of DHAP dose-density in relapsed Hodgkin lymphoma: an analysis of the German Hodgkin-Study Group

Abstract Only 50% of patients with relapsed Hodgkin lymphoma (HL) can be cured with intensive induction chemotherapy, followed by high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT). Based on the results of the HDR2 trial two courses of DHAP and subsequent HDCT/ASCT are the current standard of care in relapsed HL. In order to assess the prognostic relevance of DHAP dose density, we performed a retrospective multivariate analysis of the HDR2 trial (Nu2009=u2009266). In addition to four risk factors (early or multiple relapse, stage IV disease or anemia at relapse, and grade IV hematotoxicity during the first cycle of DHAP) a delayed start of the second cycle of DHAPu2009>u2009day 22 predicted a significantly poorer progression-free survival (PFS, pu2009=u20090.0356) and overall survival (OS, pu2009=u20090.0025). In conclusion, our analysis strongly suggests that dose density of DHAP has a relevant impact on the outcome of relapsed HL patients.

Activity of cetuximab as single agent in a patient with relapsed multiple myeloma

Multiple myeloma (MM) is a plasma cell neoplasia with a steadily increasing annual incidence of 4–6/ 100 000, accounting for an estimated 19 000 cases in the USA in 2008 [1]. Clinical symptoms frequently include osteolytic bone fractures, infections, and renal impairment, commonly with a severe impact on the patient’s quality of life [2]. Despite the introduction of novel therapeutics as proteasome inhibitors and immunomodulatory drugs (IMIDs), the treatment of MM remains challenging, since all patients relapse even after successful first-line treatment and most patients finally die of their disease [3]. Currently, high dose chemotherapy followed by autologous stem cell transplant remains the standard of care for eligible patients, and recent evidence suggests that maintenance therapy for patients who achieve complete remission might be beneficial [4]. However, effective treatment and maintenance therapy are often not feasible due to comorbidity, patient age, and toxicity of the treatment. Moreover, most patients acquire resistant disease in the course of the treatment. Therefore, novel treatment strategies that are both tolerable and effective in controlling MM are needed. The epidermal growth factor receptor (EGFR) is a member of the ErbB family of transmembrane tyrosine kinase receptors, and crucially contributes to malignant cell survival, proliferation, and metastasis of several malignancies, including colorectal cancer, head-and-neck-cancer, breast cancer, and others [5,6]. Upon ligand binding, the EGFR dimerizes in heteroor homodimers, which results in the activation of an intrinsic tyrosine kinase and the initiation of activating signaling cascades: the rasand mitogen-activated protein kinase (MAPK) pathway, and the phosphatidylinositol-3 kinase (PI3K) and protein kinase B (Akt) pathway. In addition to activating the pathways that promote cell proliferation, cell cycle progression, and cell survival, recent evidence shows that the EGFR might directly act as a transcription factor upon activation [6]. The chimeric anti-EGFR antibody cetuximab inhibits EGFR–ligand interactions and induces cell cycle arrest, apoptosis, and antibody-dependent cellular cytotoxicity (ADCC) in various malignancies. Cetuximab is approved for the treatment of metastatic colorectal cancer and relapsed/metastatic or locally advanced head-and-neck-cancer, and is currently being evaluated in clinical trials in various other epithelial malignancies [7,8]. Recent data indicate that the EGFR is expressed on the malignant plasma cells of MM and on cells of the MM microenvironment. Moreover, MM cells co-express the EGFR ligands amphiregulin and heparin-binding EGF-like growth factor (HBEGF), and inhibition of EGFR–ligand signaling induces MM cell apoptosis [9,10]. We therefore initiated an ongoing phase II clinical trial to evaluate the efficacy and safety of cetuximab in patients with relapsed MM who are not eligible for high dose chemotherapy and autologous stem cell transplant (ClinicalTrials.gov

Panobinostat consolidation in patients with Hodgkin lymphoma at risk for relapse after high dose chemotherapy and autologous stem cell transplant: final results after early trial discontinuation

Bastian von Tresckow, Franck Morschhauser, Jeffrey Szer, Dennis A. Eichenauer, Jeremy S. Abramson, Anna Sureda and Andreas Engert Department of Internal Medicine I, German Hodgkin Study Group (GHSG), University Hospital of Cologne, Kerpener Str. 62, Cologne, Germany; Hematology Department, CHRU Lille Hopital Claude Huriez, Lille, France; Bone Marrow Transplant Unit, Royal Melbourne Hospital, Parkville, VIC, Australia; Massachusetts General Hospital, Yawkey Center, Suite 9A, Boston, MA, USA; Hematology Department, Hospital De La Santa Creu I Sant Pau, Mas Casanovas, Barcelona, Spain; Hematology Department, Institut Catal a D’Oncologia – L’Hospitalet, Gran via, Barcelona, Spain

Nivolumab for adults with Hodgkin's lymphoma (a rapid review using the software RobotReviewer)

BACKGROUNDnHodgkins lymphoma (HL) is a cancer of the lymphatic system, and involves the lymph nodes, spleen and other organs such as the liver, lung, bone or bone marrow, depending on the tumour stage. With cure rates of up to 90%, HL is one of the most curable cancers worldwide. Approximately 10% of people with HL will be refractory to initial treatment or will relapse; this is more common in people with advanced stage or bulky disease. Standard of care for these people is high-dose chemotherapy and autologous stem cell transplantation (ASCT), but only 55% of participants treated with high-dose chemotherapy and ASCT are free from treatment failure at three years, with an overall survival (OS) of about 80% at three years.Checkpoint inhibitors that target the interaction of the programmed death (PD)-1 immune checkpoint receptor, and its ligands PD-L1 and PD-L2, have shown remarkable activity in a wide range of malignancies. Nivolumab is an anti-(PD)-1 monoclonal antibody and currently approved by the US Food and Drug Administration (FDA) for the treatment of melanoma, non-small cell lung cancer, renal cell carcinoma and, since 2016, for classical Hodgkins lymphoma (cHL) after treatment with ASCT and brentuximab vedotin.nnnOBJECTIVESnTo assess the benefits and harms of nivolumab in adults with HL (irrespective of stage of disease).nnnSEARCH METHODSnWe searched CENTRAL, MEDLINE, Embase, International Pharmaceutical Abstracts, conference proceedings and six study registries from January 2000 to May 2018 for prospectively planned trials evaluating nivolumab.nnnSELECTION CRITERIAnWe included prospectively planned trials evaluating nivolumab in adults with HL. We excluded trials in which less than 80% of participants had HL, unless the trial authors provided the subgroup data for these participants in the publication or after we contacted the trial authors.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently extracted data and assessed potential risk of bias. We used the software RobotReviewer to extract data and compared results with our findings. As we did not identify any randomised controlled trials (RCTs) or non-RCTs, we did not meta-analyse data.nnnMAIN RESULTSnOur search found 782 potentially relevant references. From these, we included three trials without a control group, with 283 participants. In addition, we identified 14 ongoing trials evaluating nivolumab, of which two are randomised. Risk of bias of the three included studies was moderate to high. All of the participants were in relapsed stage, most of them were heavily pretreated and had received at least two previous treatments, most of them had also undergone ASCT. As we did not identify any RCTs, we could not use the software RobotReviewer to assess risk of bias. The software identified correctly that one study was not an RCT and did not extract any trial data, but extracted characteristics of the other two studies (although also not RCTs) in a sufficient way.Two studies with 260 participants evaluated OS. After six months, OS was 100% in one study and median OS (the timepoint when only 50% of participants were alive) was not reached in the other trial after a median follow-up of 18 months (interquartile range (IQR) 15 to 22 months) (very low certainty evidence, due to observational trial design, heterogenous patient population in terms of pretreatments and various follow-up times (downgrading by 1 point)). In one study, one out of three cohorts reported quality of life. It was unclear whether there was an effect on quality of life as only a subset of participants filled out the follow-up questionnaire (very low certainty evidence). Three trials (283 participants) evaluated progression-free survival (PFS) (very low certainty evidence). Six-month PFS ranged between 60% and 86%, and median PFS ranged between 12 and 18 months. All three trials (283 participants) reported complete response rates, ranging from 12% to 29%, depending on inclusion criteria and participants previous treatments (very low certainty evidence).One trial (243 participants) reported drug-related grade 3 or 4 adverse events (AEs) only after a median follow-up of 18 months (IQR 15 to 22 months); these were fatigue (23%), diarrhoea (15%), infusion reactions (14%) and rash (12%). The other two trials (40 participants) reported 23% to 52% grade 3 or 4 AEs after six months follow-up (very low certainty evidence). Only one trial (243 participants) reported drug-related serious AEs; 2% of participants developed infusion reactions and 1% pneumonitis (very low certainty evidence).None of the studies reported treatment-related mortality.nnnAUTHORS CONCLUSIONSnTo date, data on OS, quality of life, PFS, response rate, or short- and long-term AEs are available from small uncontrolled trials only. The three trials included heavily pretreated participants, which had previously undergone regimens of BV or ASCT. For these participants, median OS was not reached after follow-up times of at least 16 months (more than 50% of participants with a limited life expectancy were alive at this timepoint). Only one cohort out of three only reported quality of life, with limited follow-up data so that meaningful conclusions were not possible. Serious adverse events occurred rarely. Currently, data are too sparse to make a clear statement on nivolumab for people with relapsed or refractory HL except for heavily pretreated people, which had previously undergone regimens of BV or ASCT. When interpreting these results, it is important to consider that proper RCTs should confirm these findings.As there are 14 ongoing trials evaluating nivolumab, of which two are RCTs, it is possible that an update of this review will be published in the near future and that this update will show different results to those reported here.