Luhong Sun

Lenalidomide in combination with rituximab for patients with relapsed or refractory mantle-cell lymphoma: a phase 1/2 clinical trial

BACKGROUND The combination of rituximab and lenalidomide has shown promise for the treatment of mantle-cell lymphoma (MCL) in preclinical studies. We aimed to identify the maximum tolerated dose (MTD) of lenalidomide when combined with rituximab in a phase 1 trial and to assess the efficacy and safety of this combination in a phase 2 trial in patients with relapsed or refractory MCL. METHODS Patients with relapsed or refractory MCL who had received one to four previous lines of treatment were enrolled in this single-arm, open-label, phase 1/2 trial at MD Anderson Cancer Center. In phase 1, to identify the MTD of lenalidomide, four patient cohorts received escalating doses (10, 15, 20, and 25 mg) of daily oral lenalidomide on days 1-21 of each 28-day cycle. 375 mg/m(2) intravenous rituximab was also administered in four weekly doses during cycle 1 only. In phase 2, patients received rituximab plus the MTD of lenalidomide, following the same cycles as for phase 1. Treatment in both phases continued until disease progression, stem-cell transplantation, or severe toxicity. The primary efficacy endpoint was overall response (complete or partial response). The secondary efficacy endpoint was survival. We used the Kaplan-Meier method to estimate response duration, progression-free survival, and overall survival. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00294632. FINDINGS 52 patients were enrolled between Feb 10, 2006 and July 30, 2009, 14 in phase 1 and 44 (including six patients who received the MTD of lenalidomide in the phase 1 portion) in phase 2. The MTD was 20 mg lenalidomide. One patient who was treated with 25 mg lenalidomide developed a grade 4 non-neutropenic infection and died. In the phase 2 portion of the study, grade 3-4 haematological toxicities included neutropenia (29 patients), lymphopenia (16 patients), leucopenia (13 patients), and thrombocytopenia (ten patients). There were only two episodes of febrile neutropenia. Among 44 patients in phase 2, 25 (57%) had an overall response: 16 (36%) had a complete response and nine (20%) had a partial response. The median response duration was 18·9 months (95% CI 17·0 months to not reached [NR]). The median progression-free survival was 11·1 months (95% CI 8·3 to 24·9 months), and the median overall survival was 24·3 months (19·8 months to NR). Five of 14 patients who had received bortezomib treatment before enrolment achieved an overall response. INTERPRETATION Oral lenalidomide plus rituximab is well tolerated and effective for patients with relapsed or refractory MCL. FUNDING Celgene.

Synergistic antitumor effects of lenalidomide and rituximab on mantle cell lymphoma in vitro and in vivo.

Rituximab (RTX), a chimeric anti‐CD20 antibody, is associated with direct induction of apoptosis and antibody‐dependent cell‐mediated cytotoxicity (ADCC) with clinical efficacy in mantle cell lymphoma (MCL). Lenalidomide (LEN), a novel immunomodulatory agent, sensitizes tumor cells and enhances ADCC. Our study attempted to elucidate the mechanism of LEN‐enhanced RTX‐mediated cytotoxicity of MCL cells. We found that LEN and RTX induced growth inhibition of both cultured and fresh primary MCL cells. LEN enhanced RTX‐induced apoptosis via upregulating phosphorylation of c‐Jun N‐terminal protein kinases (JNK), Bcl‐2, Bad; increasing release of cytochrome‐c; enhancing activation of caspase‐3, ‐8, ‐9 and cleavage of PARP. Meanwhile, LEN activated NK cells and increased CD16 expression on CD56lowCD16+ NK cells. Whole PBMCs but not NK cell‐depleted PBMCs treated with LEN augmented 30% of RTX‐dependent cytotoxicity. Daily treatment with LEN increased NK cells by 10‐folds in SCID mice, and combination of LEN and RTX decreased tumor burden and prolonged survival of MCL‐bearing SCID mice. Taken together, our study demonstrates that LEN plus RTX provides a synergistically therapeutic effect on MCL cells by enhancing apoptosis and RTX‐dependent NK cell‐mediated cytotoxicity and may be an optimal combination in the clinical trial of relapsed or refractory MCL. Am. J. Hematol. 2009.

Effect of Long-term Storage in TRIzol on Microarray-Based Gene Expression Profiling

Background: Although TRIzol is widely used for preservation and isolation of RNA, there is suspicion that prolonged sample storage in TRIzol may affect array-based gene expression profiling (GEP) through premature termination during reverse transcription. Methods: GEP on Illumina arrays compared paired aliquots (cryopreserved or stored in TRIzol) of primary samples of multiple myeloma (MM) and acute myeloid leukemia (AML). Data were analyzed at the “probe level” (a single consensus value) or “bead level” (multiple measurements provided by individual beads). Results: TRIzol storage does not affect standard probe-level comparisons between sample groups: different preservation methods did not generate differentially expressed probes (DEP) within MM or AML sample groups, or substantially affect the many DEPs distinguishing between these groups. Differences were found by gene set enrichment analysis, but these were dismissible because of instability with permutation of sample labels, unbalanced restriction to TRIzol aliquots, inconsistency between MM and AML groups, and lack of biological plausibility. Bead-level comparisons found many DEPs within sample pairs, but most (73%) were <2-fold changed. There was no consistent evidence that TRIzol causes premature reverse transcription termination. Instead, a subset of DEPs were systematically due to increased signals in TRIzol-preserved samples from probes near the 5′ end of transcripts, suggesting better mRNA preservation with TRIzol. Conclusions: TRIzol preserves RNA quality well, without a deleterious effect on GEP. Samples stored frozen with and without TRIzol may be compared by GEP with only minor concern for systematic artifacts. Impact: The standard practice of prolonged sample storage in TRIzol is suitable for GEP. Cancer Epidemiol Biomarkers Prev; 19(10); 2445–52. ©2010 AACR.

Myeloma cell line-derived, pooled heat shock proteins as a universal vaccine for immunotherapy of multiple myeloma

Tumor cell-derived heat shock proteins are used as vaccines for immunotherapy of cancer patients. However, current approaches require the generation of custom-made products and are clinically ineffective. To improve the applicability of heat shock protein-based immunotherapy in cancers and to enhance clinical efficacy, we explored combinational treatments in a myeloma setting using pooled heterogeneous or allogeneic myeloma cell line-derived glycoprotein 96 (gp96) as universal vaccines, and clearly demonstrated that pooled but not single gp96 from heterogeneous or allogeneic myeloma cell lines was as effective as autologous gp96 in protecting mice from tumor challenge and rechallenge and in treating established myeloma. We showed that interferon gamma and CD4+ and CD8+ T cells were required for gp96-induced antimyeloma responses and that pooled gp96 induced broader immune responses that protected mice from developing different myeloma. Furthermore, pooled gp96 plus CpG in combination with anti-B7H1 or anti-interleukin-10 monoclonal antibodies were effective in treating mice with large tumor burdens. Thus, this study strongly suggests that pooled gp96 vaccines from myeloma cell lines can replace gp96 vaccines from autologous tumors for immunotherapy and induce immune responses against broader tumor antigens that may protect against tumor recurrence and development of unrelated tumors in vaccinated myeloma patients.

Cyclin D1 as a universally expressed mantle cell lymphoma-associated tumor antigen for immunotherapy

Mantle cell lymphoma (MCL) accounts for 5–10% of all non-Hodgkin lymphomas and has the worst prognosis among all lymphomas. The hallmark of MCL is a t(11;14) translocation that results in overexpression of cyclin D1 by tumor cells of virtually all patients. In this study, we examined whether cyclin D1 could be an effective tumor-associated antigen for immunotherapy. We identified cyclin D1 peptides for HLA-A*0201 and generated peptide-specific CD8+ T-cell lines from HLA-A*0201+ blood donors and MCL patients. These cell lines proliferated in response to cyclin D1 peptide-pulsed stimulatory cells. Moreover, the T cells efficiently lysed peptide-pulsed but not unpulsed T2 cells and autologous dendritic cells; cyclin D1+ and HLA-A*0201+ human MCL lines MINO, SP53, Jeko-1 and Granta 519; and more importantly, HLA-A*0201+ primary lymphoma cells from MCL patients. No killing was observed with HLA-A*0201− primary lymphoma cells or HLA-A*0201+ normal blood cells, including B cells. These results indicate that these T cells are potent cytotoxic T cells and recognize cyclin D1 peptides naturally presented by patient lymphoma cells in the context of HLA-A*0201 molecules. Taken together, our work identifies cyclin D1 as a potentially important antigen for immunotherapy of MCL.

Tonic B-cell receptor signaling in diffuse large B-cell lymphoma

We used clustered regularly interspaced short palindromic repeats/Cas9-mediated genomic modification to investigate B-cell receptor (BCR) signaling in cell lines of diffuse large B-cell lymphoma (DLBCL). Three manipulations that altered BCR genes without affecting surface BCR levels showed that BCR signaling differs between the germinal center B-cell (GCB) subtype, which is insensitive to Bruton tyrosine kinase inhibition by ibrutinib, and the activated B-cell (ABC) subtype. Replacing antigen-binding BCR regions had no effect on BCR signaling in GCB-DLBCL lines, reflecting this subtypes exclusive use of tonic BCR signaling. Conversely, Y188F mutation in the immunoreceptor tyrosine-based activation motif of CD79A inhibited tonic BCR signaling in GCB-DLBCL lines but did not affect their calcium flux after BCR cross-linking or the proliferation of otherwise-unmodified ABC-DLBCL lines. CD79A-GFP fusion showed BCR clustering or diffuse distribution, respectively, in lines of ABC and GCB subtypes. Tonic BCR signaling acts principally to activate AKT, and forced activation of AKT rescued GCB-DLBCL lines from knockout (KO) of the BCR or 2 mediators of tonic BCR signaling, SYK and CD19. The magnitude and importance of tonic BCR signaling to proliferation and size of GCB-DLBCL lines, shown by the effect of BCR KO, was highly variable; in contrast, pan-AKT KO was uniformly toxic. This discrepancy was explained by finding that BCR KO-induced changes in AKT activity (measured by gene expression, CXCR4 level, and a fluorescent reporter) correlated with changes in proliferation and with baseline BCR surface density. PTEN protein expression and BCR surface density may influence clinical response to therapeutic inhibition of tonic BCR signaling in DLBCL.

Abstract 2432: The bruton's tyrosine kinase inhibitor ibrutinib synergized with the proteasome inhibitor carfilzomib and overcame immunoproteasome-mediated carfilzomib resistance in mantle cell lymphoma .

Proceedings: AACR 104th Annual Meeting 2013; Apr 6-10, 2013; Washington, DC Introduction: Mantle cell lymphoma (MCL) is not curable and novel therapeutic agents and their rational combinations are needed. The ubiquitin-proteasome pathway is an attractive target for antitumor therapy, as its persistent activity is associated with tumor formation, growth, metastasis, and drug resistance in many cancer types, including B-cell non-Hodgkin lymphoma. 20S proteasome activity is regulated by the catalytic subunits β1, β2, and β5 or in the case of the immunoproteasome (i20S) by the inducible catalytic subunits LMP2 (β1i), MECL-1(β2i), and LMP7 (β5i). Carfilzomib (CFZ), a proteasome inhibitor, inhibits the proteasome by binding specifically and irreversibly to the catalytic subunit β5/β5i. Materials and Methods: CFZ was supplied by Onyx Pharmaceuticals (South San Francisco, CA). The Btk inhibitor ibrutinib (PCI-32765) was provided by Pharmacyclics (Sunnyvale, CA). Human MCL cell lines (Mino, Jeko-1, Z138, and Rec-1) were either created by our laboratory or obtained from American Type Culture Collection. Primary cells were obtained from newly diagnosed MCL patients with informed consent. Cell viability was assessed by an MTT assay, apoptosis by Annexin V binding assays, and proteasome expression by Western blotting. Results: We found that MCL cells had different responses to CFZ. For the CFZ-sensitive MCL cell lines Mino and Z138 and freshly isolated MCL cells from 6 patients, CFZ significantly induced the growth inhibition and apoptosis at a low dose (IC50 2-6 nM). In contrast, for the CFZ-resistant MCL cell line (Rec-1) and fresh primary MCL cells from patients with clinical resistance, CFZ did not induce cell death (IC50 not reached at 100 nM). Next, Western blot analysis showed that the CFZ-resistant cells lacked expression of the i20S subunits LMP2, LMP7, and MECL-1. By contrast, the CFZ-sensitive cells showed high levels of LMP2, LMP7, and MECL-1. These results suggest that an intact immunoproteasome is necessary for CFZ-induced anti-MCL activity. In an attempt to overcome the CFZ resistance, we studied the effect of ibrutinib in CFZ-resistant MCL cells. Ibrutinib alone was toxic to both CFZ-sensitive and CFZ-resistant MCL cells with IC50 values ranging from 3 to 12.5 μM. Furthermore, we found that ibrutinib synergized with CFZ in CFZ-sensitive cell lines, and primary MCL cells. The Chou-Talay combination index was < 1, indicating synergism between the two drugs. Most importantly, the CFZ-resistant MCL cells Rec-1 were sensitive to ibrutinib, with an IC50 of 6 uM. Conclusion: Our data suggest that LMP2, LMP7, and MECL-1 may serve as potential biomarkers for patients who are likely to be sensitive to CFZ. Our data also suggest that ibrutinib may be useful in patients with CFZ-resistant MCL. Our preclinical data provide a strong rationale for testing the ibrutinib-CFZ combination clinically. Citation Format: Zhishuo Ou, Liang Zhang, Kate Newberry, Luhong Sun, Kirk J. Christopher, Alex Rollo, Archito Tamayo, John Lee, Richard J. Ford, Michael Wang, Lan V. Pham. The brutons tyrosine kinase inhibitor ibrutinib synergized with the proteasome inhibitor carfilzomib and overcame immunoproteasome-mediated carfilzomib resistance in mantle cell lymphoma . [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2432. doi:10.1158/1538-7445.AM2013-2432

Combination of atiprimod and the proteasome inhibitor bortezomib induces apoptosis of mantle cell lymphoma in vitro and in vivo.

The proteasome inhibitor bortezomib (BTZ) is known to be chemotherapeutic in relapsed or refractory mantle cell lymphoma (MCL). Atiprimod (ATI), a novel cationic amphophilic compound, has been tested in clinical trials in multiple myeloma (MM). We sought to evaluate the effect of an ATI-BTZ combination on MCL and to elucidate its therapeutic mechanisms. The ATI and BTZ combination significantly inhibited growth and induced apoptosis of both cultured MCL cell lines and freshly isolated tumor cells from patients with refractory or relapsed MCL. However, the combination yielded lower cytotoxicity in normal peripheral blood mononuclear cells (PBMC). Furthermore, ATI and BTZ induced apoptosis via two different signaling pathways. More significantly, ATI and BTZ markedly delayed tumor growth and prolonged survival in MCL-bearing NOD-SCID mice. Our results demonstrate that ATI and BTZ confer significant therapeutic effects in MCL in vitro and in vivo and should therefore be investigated in a clinical trial in patients with relapsed or refractory MCL.

Abstract 2854: Targeting constitutive NF-kB activation through Bruton's tyrosine kinase (Btk) and the proteasome in mantle cell lymphoma

Mantle cell lymphoma (MCL) is an aggressive B-cell non-Hodgkin lymphoma (NHL) with poor prognoses; novel agents are needed for its therapy. Bruton9s tyrosine kinase (Btk) has been identified as an essential kinase for B-cell survival and it is activated through the B-cell receptor (BCR) pathway. Btk has recently emerged as a promising target in MCL, as demonstrated by recent clinical trials on the Btk inhibitor PCI-32765 (Pharmacyclics, Sunnyvale, CA), suggesting that elucidating critical signaling pathways emanating through Btk will hold an important key to deciphering the pathogenesis of MCL that can lead to the development of more effective targeted therapies. In this study, we showed that Btk is constitutively phosphorylated in most MCL cell lines except Rec1 and DB SP53 and is variable among primary cells from patients. We demonstrated that knockdown of Btk by siRNA diminished Btk expression, reduced constitutive NF-kB activation by luciferase assays, leading to the cell growth inhibition and induction of apoptosis in MCL cell lines. MCL cells treated with the Btk inhibitor PCI-32765 effectively inhibits Btk activity, leading to reduced MCL cell growth with IC 50 values range from 2-6 uM in Mino, Jeko1, Z138 and JMP1. Interestingly, the IC 50 value in DB SP53, which lacks both phosphorylated Btk and membrane immunoglobulins, is 35 uM, suggesting that BCR signaling is not active in these cell lines. PCI-32765 also induced caspase-dependent apoptosis in a dose- and time-dependent manner in representative MCL cell lines and in patient primary cells. We further demonstrated that PCI-32765 down-regulates NF-kB activity through both, the canonical and alternative NF-kB pathways. Since previous studies have indicated synergy between proteasome inhibitors and tyrosine kinase inhibitors, we evaluated whether there is synergism between PCI-32765 and the next generation proteasome inhibitor Carfilzomib (Onyx Pharmaceuticals, South San Francisco, CA). Our data suggest potential synergy between Carfilzomib and PCI-32765 in represented MCL cell lines in terms of inhibiting cell growth and induction of apoptosis. Both compounds also synergize to inhibit NF-kB activation in MCL cells. In summary, our data suggest that Btk is a key survival kinase in MCL and strategic targeting of growth/survival Btk-mediated NF-kB pathways with novel therapeutic agents such as PCI-32765 should provide a novel therapy regimen for MCL patients. Combining PCI-32765 with the proteasome inhibitor Carfilzomib can synergize its effect in MCL and may be a useful therapeutic strategy, particularly for patients with relapsed/refractory MCL. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 2854. doi:1538-7445.AM2012-2854

Abstract 2177: Long-term storage in TRIzol has little effect on microarray-based gene expression profiling in primary myeloma or acute myeloid leukemia cells

We used paired samples to address whether long-term storage of cells in TRIzol has a significant effect on microarray-based gene expression profiling (GEP). The TRIzol reagent is widely used for the preservation and isolation of RNA, but there is suspicion that prolonged storage of tissues prior to RNA isolation, even at −80 C., can cause chemical modification (depurination) of RNA. This could result in early termination during reverse transcription (RT) of mRNA molecules, potentially affecting GEP more strongly for transcripts with probes located farther from the 3’ end. The Myeloma and Leukemia Tissue Banks at M. D. Anderson Cancer Center routinely collect and store primary tumor samples for research under informed consent. From these banks we selected primary tumor samples of multiple myeloma (MM; CD138+) and acute myeloid leukemia (AML; Ficoll-purified, CD3- and CD19-depleted), for which paired aliquots had been stored frozen in TRIzol (“Tri”) or cryopreservation medium (RPMI + 20% FCS + 10% DMSO, “Cryo”) since the time of initial isolation (range, 2-9 years). Cryo aliquots were quickly thawed, washed, and placed in TRIzol, then total RNA was isolated from all aliquots as per the TRIzol manufacturer9s instructions. RNA quality was assessed with a Bioanalyzer 2100 (Agilent); the RNA integrity number (RIN) was > 9 for 12/12 AML Tri, 6/12 AML Cryo, 6/6 MM Tri, and 3/6 MM Cryo samples. RNA from 12 sample pairs (6 AML, 6 MM, all with RIN > 7) was further purified with Qiagen RNAeasy columns, and the Illumina® TotalPrep RNA Amplification Kit (Ambion) was used to generate amplified, biotinylated cRNA after RT by the Eberwine procedure. Bioanalyzer-generated histograms of cRNA were similar for all sample aliquots, suggesting no early termination of RT due to TRIzol. GEP was performed with cRNA on Illumina HT-12 BeadArrays. Analysis of “probe-level” data with GenomeStudio software (Illumina), after median normalization, showed excellent concordance between sample Tri/Cryo pairs for all but probes with low intensities ( 13 for any sample pair, and most pairs had Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2177.