Gianpaolo Marcacci

Biweekly rituximab, cyclophosphamide, vincristine, non-pegylated liposome-encapsulated doxorubicin and prednisone (R-COMP-14) in elderly patients with poor-risk diffuse large B-cell lymphoma and moderate to high 'life threat' impact cardiopathy.

This Phase II study assessed feasibility and efficacy of a biweekly R‐COMP‐14 regimen (rituximab, cyclophosphamide, non‐pegylated liposome‐encapsulated doxorubicin, vincristine and prednisone) in untreated elderly patients with poor‐risk diffuse large B‐cell lymphoma (DLBCL) and moderate to high ‘life threat’ impact NIA/NCI cardiac comorbidity. A total of 208 courses were delivered, with close cardiac monitoring, to 41 patients (median age: 73 years, range: 62–82; 37% >75 years) at a median interval of 15·6 (range, 13–29) days; 67% completed all six scheduled courses. Response rate was 73%, with 68% complete responses (CR); 4‐year disease‐free survival (DFS) and time to treatment failure (TTF) were 72% and 49%, respectively. Failures were due to early death (n = 3), therapy discontinuations (no‐response n = 2; toxicity n = 6), relapse (n = 6) and death in CR (n = 3). Incidence of cardiac grade 3–5 adverse events was 7/41 (17%; 95% confidence interval: 8–31%). Time to progression and overall survival at 4‐years were 77% and 67%, respectively. The Age‐adjusted Charlson Comorbidity Index (aaCCI) correlated with failures (P = 0·007) with patients scoring ≤7 having a longer TTF (66% vs. 29%; P = 0·009). R‐COMP‐14 is feasible and ensures a substantial DFS to poor‐risk DLBCL patients who would have been denied anthracycline‐based treatment due to cardiac morbidity. The aaCCI predicted both treatment discontinuation rate and TTF.

Fotemustine plus etoposide, cytarabine and melphalan (FEAM) as a new conditioning regimen for lymphoma patients undergoing auto-SCT: a multicenter feasibility study.

BEAM is a widely used conditioning regimen for relapsed/refractory lymphoma patients undergoing auto-SCT. We conducted a multicenter study with an alternative regimen (fotemustine plus etoposide, cytarabine and melphalan (FEAM)) in which BCNU was substituted by the chloroethylnitrosourea fotemustine (FTM). Eighty-four patients with relapsed/refractory Hodgkins (n=20) and non-Hodgkins lymphoma (n=64) were conditioned with a FEAM regimen (FTM 150 mg/m2 on days –7, –6, etoposide 200 mg/m2 and cytarabine 400 mg/m2 on days –5, –4, –3, –2 and melphalan 140 mg/m2 on day –1). Patients were evaluated for toxicity and engraftment parameters. Median times to neutrophil (>500 × 109/l) and plt (>20 000 × 109/l) engraftment were 11 and 13 days, respectively. Grade 3 mucositis occurred in 19 patients (23%), while G3 nausea/vomiting and G3 diarrhea were observed in 13 (15%) and 6 (7%) patients, respectively. No severe hepatic, renal or pulmonary toxicity was detected. Seven patients (7%) experienced G4 mucositis, while no other G4 toxicities or unexpected adverse events of any grade were recorded. Transplant-related mortality was 2.4%. We conclude that a FEAM regimen is feasible and safe. Although toxicity and engraftment times compared favorably with BEAM, longer follow-up is needed to evaluate fully its efficacy and long-term safety.

Tumor flare reactions and response to lenalidomide in patients with refractory classic Hodgkin lymphoma

Patients with Hodgkin lymphoma (HL) failing salvage stem cell transplantation are candidates to investigational strategies. Lenalidomide represents an attractive option as it targets several signaling pathways, which regulate survival of HL cells and their microenvironmental interactions. We report the occurrence of Grades 2 and 3 tumor flare reactions in the first three patients entered a lenalidomide-based compassionate program for treatment-refractory HL. Flares occurred in concomitance of the scheduled week-off lenalidomide and upon withdrawal of symptomatic steroid treatment, and were associated with changes in B-cell regulatory cytokines and the concurrent expansion of polyclonal B-cells. Flares mimicked tumor progression but were effectively managed with anti-inflammatory treatment and followed by a clinical response, suggesting that they may mirror the pleiotropic actions of lenalidomide on HL microenvironment.

Improved outcome of patients with relapsed/refractory Hodgkin lymphoma with a new fotemustine‐based high‐dose chemotherapy regimen

High‐dose chemotherapy (HDT) with autologous stem cell transplantation is the standard of care for relapsed/refractory (RR) Hodgkin lymphoma (HL). Given that HDT may cure a sizeable proportion of patients refractory to first salvage, development of newer conditioning regimens remains a priority. We present the results of a novel HDT regimen in which carmustine was substituted by a third‐generation chloroethylnitrosourea, fotemustine, with improved pharmacokinetics and safety (FEAM; fotemustine, etoposide, cytarabine, melphalan) in 122 patients with RR‐HL accrued into a prospective registry‐based study. Application of FEAM resulted in a 2‐year progression‐free survival (PFS) of 73·8% [95% confidence interval (CI), 0·64–0·81] with median PFS, overall survival and time to progression yet to be reached. The 2‐year risk of progression adjusted for the competitive risk of death was 19·4% (95% CI, 0·12–0·27) for the entire patient population. Most previously established independent risk factors, except for fluorodeoxyglucose (18FFDG)‐uptake, were unable to predict for disease progression and survival after FEAM. Although 32% of patients had 18FFDG‐positrin emission tomography‐positive lesions before HDT, the 2‐year risk of progression adjusted for competitive risk of death was 19·4% (95% CI; 0·12–0·27). No unusual acute toxicities or early/late pulmonary adverse events were registered. FEAM emerges as an ideal HDT regimen for RR‐HL patients typically pre‐exposed to lung‐damaging treatments.

A phase II study of dose‐dense and dose‐intense ABVD (ABVDDD‐DI) without consolidation radiotherapy in patients with advanced Hodgkin lymphoma

We explored activity and safety of a dose‐dense/dose‐intense adriamycin, bleomycin, vinblastine and dacarbazine regimen (ABVDDD‐DI) in 82 patients with advanced Hodgkin Lymphoma. Patients entered a two‐stage Bryant‐Day Phase II study to receive six cycles of ABVDDD‐DI without consolidation radiotherapy. Cycles were supported with granulocyte colony‐stimulating factor and delivered every 21 d; drugs were administered on days 1 and 11 at the same doses of standard ABVD except for doxorubicin (35 mg/m2; first four cycles only). Co‐primary endpoints were complete response (CR) rate and severe acute cardiopulmonary toxicity; secondary endpoints were event‐free (EFS) and disease‐free survival (DFS). All patients received the four doxorubicin‐intensified courses and 96% concluded all six cycles (82·3% within the intended 18 weeks). This translated into a 66·9% increase of received dose‐intensity for doxorubicin and 31·8% for the other agents over standard ABVD. The CR rate was 95·1% (78/82) and 87·8% (72/82) achieved a metabolic CR after two cycles. Cardiopulmonary toxicity never exceeded grade 2 and affected 14·6% of patients. Most frequent toxicities were grade 4 neutropenia (10%) and anaemia (9%), grade 3 infection (17%) and grade 2 mucocutaneous changes (30%). Five‐year EFS and DFS was 88·3% and 93·7%, respectively. ABVDDD‐DI regimen was well‐tolerated and ensured substantial CR and EFS rates without radiotherapy.

Efficacy and safety of the third-generation chloroethylnitrosourea fotemustine for the treatment of chemorefractory T-cell lymphomas

Patients with recurring T‐cell non‐Hodgkin lymphoma (T‐NHL) are incurable and candidate for investigational agents. Here, we report on five patients with T‐NHL refractory to multiple chemotherapy lines, including in all cases alkylators and gemcitabine, who received the third‐generation chloroethylnitrosourea fotemustine at a dose of 120 mg/m2 every 21 d, up to eight courses. Median actual dose intensity was 79%; toxicity was manageable and mainly hematological. One complete remission, one partial remission, two protracted disease stabilization, and one transient, minor response were achieved. Time to progression ranged from 48 to 240+ d. This is the first evidence ever reporting the activity of fotemustine in end‐stage T‐NHL. Formal studies with this agent are warranted in T‐cell malignancies.

Abstract 394: Rapid and persistant neutrophil mobilization by novel CXCR4 peptide antagonists

Proceedings: AACR 102nd Annual Meeting 2011‐‐ Apr 2‐6, 2011; Orlando, FL Introduction: The CXCR4 inhibitor AMD3100 is FDA-approved to provide stem cell mobilization for autologous transplantation in NHL and Multiple Myeloma patients. Newly designed CXCR4 inhibitory molecules, named Hys-7 inv, Phe-7 inv and Hys-OH, were recently discovered and validated in in vitro and in vivo studies (patent MI2010A-000093). Aim of the study was to evaluate the role of new CXCR4 inhibitors in hematopoietic stem cell and neutrophil mobilization. Experimental procedures: 60 DBA/2 female were injected subcutaneously with 5 or 30 mg/kg of CXCR4 antagonist in comparison with AMD3100 (3 or 20 mg/kg). Blood was collected at 1, 2, 6 and 24 hours from the treatment. Neutrophilis were evaluated trough flow cytometry (Ly-6G+ cells) and colony forming unit assay (CFU) of the mobilized stem cell were performed. Bone marrow was also evaluated through flow cytometry and cytological analysis. Results: Hys-7 inv, Phe-7 inv and Hys-OH, cyclic peptides CXCR4 antagonists, induced potent stem cell and neutrophils mobilization compared with AMD3100. Treatment resulted in a rapid and dose related increment in neutrophils count as well as hematopoietic stem and progenitor cells increase in peripheral blood (2 to 5 fold increase). Although Hys-7inv and Hys-OH induced neutrophils increment similar to AMD3100 the kinetic was different. AMD3100 (20 mg/kg) mobilized Ly-6G cells within 1 hour but transiently (no increase at 24 hours); instead Hys-7inv and Hys-OH mobilized Ly-6G within 2 hours lasting up to 24 hours. Interestingly, Phe-7 inv increased neutrophils mobilization within 1 hour lasting up to 24 hours. AMD3100 treated bone marrow showed an increase in progenitor cells myelo-committed (from 1.5 to 3 fold increase) and polimorphonuclear cells (PMN) (1.5 to 2.5 fold increase) and a reduction in mature-lymphocyte (0.4 to 0.28 fold increase); CXCR4 inhibitor peptides increased the immature myelo-committed progenitor cells (from 2 to 3 fold increase VS control) compared with AMD3100 (1.5 fold increase VS control) reducing PMN (1.5 to 1.65 fold increase) compared to AMD3100 (2.5 fold increase). CFU showed increased colonies in peripheral blood from mice treated with cyclic-peptides (from 2.5 to 4 fold increase) compared to AMD3100 (3.5 fold increase); the highest number of CFU was reached earlier in mice treated with Hys-7inv, Phe-7 inv and Hys-OH rapidly (within 1h) versus AMD3100 (6 hours). Conclusions: In vivo studies demonstrated that three newly synthesized CXCR4 inhibitors increased neutrophil and hematopoietic stem cells release from the bone marrow with different kinetic and duration compared to the FDA approved stem cell mobilizer AMD3100. Ongoing experiments are evaluating advantages in mobilizing precursors cells with CXCR4 cyclic-peptides antagonists compared to AMD3100. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 394. doi:10.1158/1538-7445.AM2011-394