Fiona Miall

Rituximab versus a watch-and-wait approach in patients with advanced- stage, asymptomatic, non-bulky follicular lymphoma: an open-label randomised phase 3 trial

BACKGROUNDnPatients with advanced-stage, low-tumour-burden follicular lymphoma have conventionally undergone watchful waiting until disease progression. We assessed whether rituximab use could delay the need for chemotherapy or radiotherapy compared with watchful waiting and the effect of this strategy on quality of life (QoL).nnnMETHODSnAsymptomatic patients (aged ≥18 years) with low-tumour-burden follicular lymphoma (grades 1, 2, and 3a) were randomly assigned centrally (1:1:1), by the minimisation approach stratified by institution, grade, stage, and age, to watchful waiting, rituximab 375 mg/m(2) weekly for 4 weeks (rituximab induction), or rituximab induction followed by a maintenance schedule of 12 further infusions given at 2-monthly intervals for 2 years (maintenance rituximab). On Sept 30, 2007, recruitment into the rituximab induction group was closed and the study was amended to a two-arm study. The primary endpoints were time to start of new treatment and QoL at month 7 (ie, 6 months after completion of rituximab induction). All randomly assigned patients were included in the analysis of time to start of new treatment on an intention-to-treat basis. The main study is now completed and is in long-term follow-up. The study is registered with ClinicalTrials.gov, NCT00112931.nnnFINDINGSnBetween Oct 15, 2004, and March 25, 2009, 379 patients from 118 centres in the UK, Australia, New Zealand, Turkey, and Poland were randomly assigned to watchful waiting or maintenance rituximab. 84 patients were recruited to the rituximab induction group before it was closed early. There was a significant difference in the time to start of new treatment, with 46% (95% CI 39-53) of patients in the watchful waiting group not needing treatment at 3 years compared with 88% (83-92) in the maintenance rituximab group (hazard ratio [HR] 0·21, 95% CI 0·14-0·31; p<0·0001). 78% (95% CI 69-87) of patients in the rituximab induction group did not need treatment at 3 years, which was significantly more than in the watchful waiting group (HR 0·35, 95% CI 0·22-0·56; p<0·0001), but no different compared with the maintenance rituximab group (0·75, 0·41-1·34; p=0·33). Compared with the watchful waiting group, patients in the maintenance rituximab group had significant improvements in the Mental Adjustment to Cancer scale score (p=0·0004), and Illness Coping Style score (p=0·0012) between baseline and month 7. Patients in the rituximab induction group did not show improvements in their QoL compared with the watchful waiting group. There were 18 serious adverse events reported in the rituximab groups (four in the rituximab induction group and 14 in the maintenance rituximab group), 12 of which were grade 3 or 4 (five infections, three allergic reactions, and four cases of neutropenia), all of which fully resolved.nnnINTERPRETATIONnRituximab monotherapy should be considered as a treatment option for patients with asymptomatic, advanced-stage, low-tumour-burden follicular lymphoma.nnnFUNDINGnCancer Research UK, Lymphoma Research Trust, Lymphoma Association, and Roche.

CD49d is an independent prognostic marker that is associated with CXCR4 expression in CLL

The world of chronic lymphocytic leukemia (CLL) research is awash with prognostic markers. However, very few of the current group play a clearly defined role in the pathology of this disease and even fewer represent a tractable therapeutic target. One such marker that fulfils both of these criteria is the integrin CD49d. This molecule been implicated in the capacity of CLL cells to migrate into lymphoid tissues and there is a CD49d blocking antibody, Natalizumab, currently in clinical trials. Here we carried out the largest multi-centre evaluation of CD49d as a prognostic marker in 652 primary CLL samples. We confirm that CD49d is predictive for time to first treatment (P<0.0001) and overall survival (P<0.0001) and increases the prognostic power of CD38, ZAP-70 and IGHV gene mutation status in concordant cases. Furthermore, CD49d retained independent prognostic significance in multivariate analysis. In contrast to previous studies, we showed no correlation between CD49d expression and in vitro resistance to fludarabine in liquid cultures (P=0.28) but CD49d(hi) cells were significantly more resistant than CD49d(lo) cells when assays were carried out on fibronectin-coated plates (P=0.03). Furthermore, we showed for the first time that the expression of CD49d is strongly associated with expression of the chemokine receptor CXCR4 suggesting a co-ordinated role for these molecules in the trafficking of CLL cells to the lymphoid tissues. Taken together, our data support the introduction of CD49d into routine immunophenotyping panels for CLL and indicate that the therapeutic targeting of this molecule may prove useful in this disease.

Enhancement of CD154/IL4 proliferation by the T follicular helper (Tfh) cytokine, IL21 and increased numbers of circulating cells resembling Tfh cells in chronic lymphocytic leukaemia.

Chronic lymphocytic leukaemia (CLL) cells encounter T‐cells and proliferate in response to T‐cell signals in the lymph node microenvironment. In this report we determined interleukin 21 (IL21) function in CLL and showed that IL21 and interleukin 4 (IL4) act co‐operatively to promote leukaemic cell proliferation without apoptosis or differentiation We further show that IL21 increased side population (SP) cells, which are associated with resistance to chemotherapy and increased self‐renewal capacity in CLL. IL21 and IL4 are the major cytokines produced by the recently described CD4+ T follicular helper (Tfh) cell subset. Determination of Tfh cells in peripheral blood showed that patients had significantly increased numbers as compared to normal subjects although no association was found between Tfh numbers and IGHV gene mutational status or clinical stage. Our data suggests that the Tfh cytokines, IL4 and IL21, contribute to driving leukaemic cell proliferation in the lymph node microenvironment, and may contribute to the specific production of cells resistant to conventional chemotherapy. We suggest that increased circulating Tfh cells is a component of T‐cell dysregulation in CLL. Our findings have implications for the therapeutic use of IL21.

Pyoderma gangrenosum complicating pegylated granulocyte colony‐stimulating factor in Hodgkin lymphoma

Pegylated granulocyte colony-stimulating factor (GCSF) (Pegfilgrastim/Neulasta, Amgen, Thousand Oaks, CA, USA) is a covalent conjugate of recombinant human GCSF and monomethoxypolyethyene glycol. Its advantage over regular GCSF is its reduced renal clearance and consequent prolonged persistence in vivo, allowing it to be administered in a single subcutaneous injection, once per cycle of chemotherapy. Pegylated GCSF does not routinely result in marked neutrophilia because serum clearance is directly related to the number of neutrophils. It is being used increasingly in oncology as a simple and cost-effective means of maintaining adequate neutrophil levels during intensive combination chemotherapy. We report here the occurrence of pyoderma gangrenosum following pegylated GCSF in a patient being treated for advanced Hodgkin lymphoma, who had previously received regular GCSF without incident. A previously fit 21-year-old female presented with clinical stage IIIB nodular sclerosing Hodgkin lymphoma. She was treated with combination chemotherapy according to the Adriamycin, Bleomycin, Vinblastine and Doxorubicin (ABVD) protocol. She was admitted to hospital following cycles 1A and 1B of chemotherapy with constipation and a urinary tract

TP53 codon 72 polymorphism in patients with chronic lymphocytic leukaemia: identification of a subgroup with mutated IGHV genes and poor clinical outcome

To the Editor, IGHV mutational status remains the most reliable prognostic indicator in CLL, but there is clinical heterogeneity within the mutated and unmutated groups. Mutated IGHV status does not preclude progression and, indeed, a subset of individuals with mutations will go on to develop aggressive disease. Thus, additional markers would be useful in the identification of those individuals with mutated IGHV genes, but who progress and need therapeutic intervention. TP53 deletion or dysfunction has a major influence on prognosis and response to treatment in CLL. A major polymorphism occurring in the TP53 gene, is the G/C SNP at codon 72, resulting in either an arginine (Arg72;GG) or proline (Pro72;CC). Arg72 has a greater apoptotic potential, increases the ability of p53 to locate to the mitochondria and binds more strongly to MDM2 (Dumont et al, 2003), an important negative regulator of TP53. The two TP53 variants have also been shown to exert different effects on cell cycle progression (Pim & Banks, 2004) and this polymorphism exhibits a large ethnic variability. In Northern Europeans the Pro72 haplotype is present in 10% of the population but in Nigeria it is found in 63% (Sjalander et al, 1995). The influence of the codon 72 SNP on the development of malignancy has been studied in the general population and Pro72/Pro72 is associated with improved survival in several forms of cancer as compared to Arg72/Arg72 (Orsted et al, 2007). The association between codon 72 polymorphisms and clinical outcomes has been investigated (Sturm et al, 2005; Kochethu et al, 2006) and no significant effects were found. However, both studies were relatively small (138 and 203 patients respectively) and neither estimated ascertainment bias by measuring the Hardy–Weinberg equilibrium. One study (Sturm et al, 2005) selected patients with high white cell counts. Therefore, we undertook a larger study with unselected patients and also established that there was no ascertainment bias in our cohort. We correlated codon 72 SNPs with age at diagnosis, time from diagnosis to first treatment, progression free survival and overall survival. We also sought associations of the codon 72 SNP with IGHV gene mutational status and, because the study had sufficient patients, we were able to analyze the effects of the SNP on clinical outcomes within the group of patients with M-CLL. Samples were collected following informed, written consent in accordance with the Declaration of Helsinki and with local research ethics committee approval. Diagnosis was made by standard immunophenotypic criteria on peripheral blood samples. The frequency of the TP53 codon 72 SNP was assessed using PCR and direct sequencing and correlated with IGHV mutational status, analyzed using BIOMED2 primers and IGMT (http://imgt.cines.fr). Statistical analysis was performed using Prism 3.0 (GraphPad Software Inc., La Jolla, CA, USA). Time to first treatment (TTFT) and overall survival (OS) curves were constructed using the method of Kaplan and Meier, and Cox proportional hazards analysis. Significance was assumed at P < 0Æ05. We analyzed 433 patients: mean age at diagnosis was 66 years (range 33–97) and the M:F ratio was 1Æ9:1. At diagnosis, 335 were Binet stage A, 69 stage B and 29 stage C. Three hundred and seven patients had mutated and 123 unmutated IGHV genes, using a 2% mutation rate as the threshold for cut-off. A further three patients appeared to have both mutated and unmutated V gene usage and were not included in the study. The TP53 codon 72 genotype frequencies we observed in our cohort were GG = 54%, CC = 8% and CG = 38%, similar to those reported in previous studies (Orsted et al, 2007) (test for Hardy–Weinberg equilibrium: P = 0Æ8). Sixteen patients were of southern Asian (predominantly Gujerati) origin, and showed frequencies of 18Æ75% for both the GG and CC TP53 alleles and 62Æ5% for the CG, possibly reflecting the different genotypic frequencies this SNP exhibits across different ethnic populations. We found an association between the TP53 SNPs and mutational status, which has not been previously noted. Homozygous GG (Arg72/Arg72) at codon 72 was present in more U-CLL than M-CLL, whereas CC (Pro72/Pro72) was enriched in M-CLL (Fig 1A). In those patients with mutated IGHV gene segments, we found that CC (n = 22) was associated with a significantly shorter TTFT than GG (n = 157) (HR = 9Æ7; P = 0Æ0002; median days 1372 and 6393, Fig 1B). The TTFT of the GG group was similar to that of the entire group of patients with M-CLL. Thus, within M-CLL those patients with the TP53 SNP CC have a TTFT similar to that of patients with U-CLL. Previous studies have also not observed differences in clinical outcome. However, the TP53 CC group (n = 34) had significantly shorter TTFT than the GG SNP patients (n = 235): hazard ratio (HR) 3Æ6 (95% CI 1Æ4–8Æ6) P = 0Æ0042, median days 2388 and 6393 respectively, whereas the median TTFT for the heterozygote group was not reached (Fig 1C). Correspondence

A Double Hit CD10-Negative B-Cell Lymphoma with t(3;8)(q27;q24) Leading to Juxtaposition of the BCL6 and MYC Loci Associated with Good Clinical Outcome

The WHO classification of lymphomas allows for a group of diseases that have features intermediate between those of Burkitt lymphoma and diffuse large B-cell lymphoma. These are a diverse group of diseases whose genetics and clinical course are yet to be fully described. We report an unusual case of high grade B-cell lymphoma, intermediate between DLBCL and BL, lacking CD10 expression in which the chromosomal translocation t(3;8)(q27;q24) was found to be the sole chromosomal abnormality. FISH analysis demonstrated juxtaposition of the BCL6 and MYC loci without obvious involvement of the IGH locus, suggesting constitutive MYC expression due to promoter substitution. The patient responded to intensive chemotherapy and remains in remission two years after finishing therapy.

Obinutuzumab-induced coagulopathy in chronic lymphocytic leukaemia with trisomy 12.

We thank the patient and her family for participating in this clinical trial and the nGP28331 study site staff on the Hope Unit at the Leicester Royal Infirmary. We also nthank Dr Gregory Vosganian and his colleagues at Genentech and Roche for their help nand review of the case. Studies were supported by the Leicester Experimental Cancer nMedicine Centre (C325/A15575 Cancer Research UK/UK Department of Health).

Defining the prognosis of early stage chronic lymphocytic leukaemia patients

Approximately 70% of chronic lymphocytic leukaemia (CLL) patients present with early stage disease, therefore defining which patients will progress and require treatment is a major clinical challenge. Here, we present the largest study of prognostic markers ever carried out in Binet stage A patients (nu2003=u20031154) with a median follow‐up of 8u2003years. We assessed the prognostic impact of lymphocyte doubling time (LDT), immunoglobulin gene (IGHV) mutation status, CD38 expression, ZAP‐70 expression and fluorescence in situ hybridization (FISH) cytogenetics with regards to time to first treatment (TTFT) and overall survival (OS). Univariate analysis revealed LDT as the most prognostic parameter for TTFT, with IGHV mutation status most prognostic for OS. CD38 expression, ZAP‐70 expression and FISH were also prognostic variables; combinations of these markers increased prognostic power in concordant cases. Multivariate analysis revealed that only LDT, IGHV mutation status, CD38 and age at diagnosis were independent prognostic variables for TTFT and OS. Therefore, IGHV mutation status and CD38 expression have independent prognostic value in early stage CLL and should be performed as part of the routine diagnostic workup. ZAP‐70 expression and FISH were not independent prognostic markers in early stage disease and can be omitted at diagnosis but FISH analysis should be undertaken at disease progression to direct treatment strategy.

Defining the prognosis of early stage chronic lymphocytic leukaemia patients.

Approximately 70% of chronic lymphocytic leukaemia (CLL) patients present with early stage disease, therefore defining which patients will progress and require treatment is a major clinical challenge. Here, we present the largest study of prognostic markers ever carried out in Binet stage A patients (nu2003=u20031154) with a median follow‐up of 8u2003years. We assessed the prognostic impact of lymphocyte doubling time (LDT), immunoglobulin gene (IGHV) mutation status, CD38 expression, ZAP‐70 expression and fluorescence in situ hybridization (FISH) cytogenetics with regards to time to first treatment (TTFT) and overall survival (OS). Univariate analysis revealed LDT as the most prognostic parameter for TTFT, with IGHV mutation status most prognostic for OS. CD38 expression, ZAP‐70 expression and FISH were also prognostic variables; combinations of these markers increased prognostic power in concordant cases. Multivariate analysis revealed that only LDT, IGHV mutation status, CD38 and age at diagnosis were independent prognostic variables for TTFT and OS. Therefore, IGHV mutation status and CD38 expression have independent prognostic value in early stage CLL and should be performed as part of the routine diagnostic workup. ZAP‐70 expression and FISH were not independent prognostic markers in early stage disease and can be omitted at diagnosis but FISH analysis should be undertaken at disease progression to direct treatment strategy.