Theresa R. Pacheco

Phase IIB Multicenter Trial of Vorinostat in Patients With Persistent, Progressive, or Treatment Refractory Cutaneous T-Cell Lymphoma

PURPOSE To evaluate the activity and safety of the histone deacetylase inhibitor vorinostat (suberoylanilide hydroxamic acid) in persistent, progressive, or recurrent mycosis fungoides or Sézary syndrome (MF/SS) cutaneous t-cell lymphoma (CTCL) subtypes. PATIENTS AND METHODS Patients with stage IB-IVA MF/SS were treated with 400 mg of oral vorinostat daily until disease progression or intolerable toxicity in this open-label phase IIb trial (NCT00091559). Patients must have received at least two prior systemic therapies at least one of which included bexarotene unless intolerable. The primary end point was the objective response rate (ORR) measured by the modified severity weighted assessment tool and secondary end points were time to response (TTR), time to progression (TTP), duration of response (DOR), and pruritus relief ( > or = 3-point improvement on a 10-point visual analog scale). Safety and tolerability were also evaluated. RESULTS Seventy-four patients were enrolled, including 61 with at least stage IIB disease. The ORR was 29.7% overall; 29.5% in stage IIB or higher patients. Median TTR in stage IIB or higher patients was 56 days. Median DOR was not reached but estimated to be >or = 185 days (34+ to 441+). Median TTP was 4.9 months overall, and 9.8 months for stage IIB or higher responders. Overall, 32% of patients had pruritus relief. The most common drug-related adverse experiences (AE) were diarrhea (49%), fatigue (46%), nausea (43%), and anorexia (26%); most were grade 2 or lower but those grade 3 or higher included fatigue (5%), pulmonary embolism (5%), thrombocytopenia (5%), and nausea (4%). Eleven patients required dose modification and nine discontinued due to AE. CONCLUSION Oral vorinostat was effective in treatment refractory MF/SS with an acceptable safety profile.

Evaluation of the long-term tolerability and clinical benefit of vorinostat in patients with advanced cutaneous T-cell lymphoma.

INTRODUCTION Vorinostat, an orally active histone deacetylase inhibitor, was approved in October 2006 by the US Food and Drug Administration for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma (CTCL) in patients with progressive, persistent, or recurrent disease during or after treatment with 2 systemic therapies. PATIENTS AND METHODS A multicenter, open-label phase IIb trial evaluated the activity and safety of vorinostat 400 mg orally daily in patients with > or = stage IB, persistent, progressive, or treatment-refractory mycosis fungoides or Sézary syndrome CTCL subtypes. We report the safety and tolerability of long-term vorinostat therapy in patients who experienced clinical benefit in the previous phase IIb study. RESULTS As of December 11, 2008, 6 of 74 patients enrolled in the original study had received vorinostat for > or = 2 years: median age, 65 years; median number of previous therapies, 2.5; median time from diagnosis to enrollment, 1.8 years. At enrollment into the continuation phase, 5 of the 6 patients had achieved an objective response, and 1 patient had prolonged stable disease. During the follow-up study, the most common drug-related grade 1-4 adverse events (AEs) were diarrhea, nausea, fatigue, and alopecia (6, 5, 4, and 3 patients, respectively). Incidence of grade 3/4 AEs was low: anorexia (n = 1), increased creatinine phosphokinase (n = 1), pulmonary embolism (n = 1), rash (n = 1), and thrombocytopenia (n = 1). Five patients have discontinued the study drug, and 1 patient is continuing therapy. CONCLUSION This post hoc subset analysis provides evidence for the long-term safety and clinical benefit of vorinostat in heavily pretreated patients with CTCL, regardless of previous treatment failures.

Parallel genehunter: implementation of a linkage analysis package for distributed-memory architectures

We present a parallel algorithm for performing multipoint linkage analysis of genetic marker data on large family pedigrees. The algorithm effectively distributes both the computation and memory requirements of the analysis. We discuss an implementation of the algorithm in the Genehunter linkage analysis package (version 2.1), enabling Genehunter to run on distributed-memory platforms for the first time. Our preliminary benchmarks indicate reasonable scalability of the algorithm even for fixed-size problems, with parallel efficiencies of 75% or more on up to 128 processors. In addition, we have extended the hard-coded limit of 16 non-founding individuals in Genehunter 2.1 to a new limit of 32 non-founding individuals.

Extramedullary plasmacytoma in cardiac transplant recipients

Extramedullary plasmacytomas are an immunoproliferative, monoclonal disease of B-cell lineage and are classified as non-Hodgkins lymphomas. Cutaneous extramedullary plasmacytomas are rare. We report 2 cases of transplantation-associated cutaneous extramedullary plasmacytomas in a setting of chronic immunosuppression.

SASH1 Is Involved in an Autosomal Dominant Lentiginous Phenotype.

Yiqun G. Shellman1,*, Karoline A. Lambert1, Anne Brauweiler1, Pamela Fain2,3, Richard A. Spritz2, Melanie Martini4, Klaus-Peter Janssen4, Neil F. Box5, Tamara Terzian5, Marian Rewers3, Anelia Horvath6, Constantine A. Stratakis6, William A Robinson7, Steven E. Robinson7, David A. Norris1, Kristin B Artinger8, and Theresa R. Pacheco1,* 1Department of Dermatology, University of Colorado Anschutz Medical Campus, School of Medicine, Mail Stop 8127, k Aurora, CO 80045

Genetic heterogeneity in the multiple lentigines/LEOPARD/Noonan syndromes.

Multiple lentigines (ML)/LEOPARD syndrome (MIM 151100) is a rare autosomal dominant disorder. Affected individuals suffer diffuse cutaneous lentigines and a variety of other non-cutaneous manifestations, mainly cardiac, auditory, and developmental abnormalities. Noonan syndrome (MIM 163950) is an autosomal dominant disorder characterized by unusual facial features, short stature, and skeletal and cardiac anomalies. Some affected individual display cutaneous lentigines. Recent reports characterizing the ML/LEOPARD syndrome and the Noonan syndrome as allelic disorders are based on the finding that both syndromes may be caused by mutations in the PTPN11 gene (MIM 176876) [Digilio et al., 2002; Legius et al., 2002]. Here we show that nonsyndromicML can be inherited as a distinct entity cause by mutations in a novel gene on chromosome 6. The family is of Hispanic origin with 13 family members from 4 generations affected with ML (Fig. 1). The diagnosis of ML was based on the presence of multiple small 1–5mmhyperpigmentedmacules on the entire body excepting palmar and plantar surfaces (Fig. 2). All 29 family members who donated blood samples for the study were examined for ML by a dermatologist. Although several affected family members exhibited undefined learning disabilities and hearing impairments, none of them exhibited developmental cardiac defects or other overt phenotypic features of LEOPARD syndrome. The Colorado Multiple Institutional Review Board approved the protocols for the study. DNA was prepared from peripheral blood samples using the Qiagen Maxi kit (Qiagen, Inc., Valencia, CA). A total of 19 family members were genotyped for 380 markers using the ABI Linkage Mapping Set version 2.5-MD5 (Applied Biosystems, Foster City, CA). Linkage infromativeness for regions with suggestive linkage was increased by genotyping a higher density of markers from ABI. PCR products generated with an ABI 877 Integrated Thermal Cycler Genotyping were loaded onto an ABI 377 DNA Sequencer for automated fluorescent microsatellite analysis. DNA fragment sizing and allele calling was performed using ABI GeneScan andGenotyper analysis software, respectively. Pairwise LODs were calculated using the LINKAGE software package assuming autosomal dominant inheritance of ML with high (0.8) penetrance and a disease gene frequency of 0.0001. LODs from pairwise linkage analysis are shown in Table I. The results are definitive in positioning the ML locus in the 10 cM region between markers D6S308 and D6S411 based on a maximum LOD of 4.129 at marker D6S1654 (odds favoring linkage>10,000:1), and a 1-lod confidence interval. As shown in Figure 1, the segregation of chromosome 6q haplotypes supports the statistical evidence for linkage with three recombinants confirming a position for the ML locus proximal to marker D6S441 (V:31, IV:11, IV:22), and one recombinant (V:29) confirming a position distal to marker D6S308. Significant clinical overlap exists between Noonan syndrome and ML, and it is not surprising some identified cases of LEOPARD syndrome are a subtype of the Noonan syndrome. But our data suggest that the non-syndromic ML is a distinct entity and is not a subtype of either Noonan or LEOPARD syndrome. This work extends previous studies in the same family in which we excluded PTPN11 as well as the genes for other clinically overlapping disorders, including neurofibromatosis type 1 (NF1), Carney syndrome types I and II (CNC1 and CNC2), Peutz–Jeghers syndrome (PJS), and Cowden disease (CD) [Pacheco et al., 2002]. Other groups suggest that distinct mutations affecting the PTPN11 phosphotyrosine phosphatase domain explain the cutaneous anomalies seen in ML/LEOPARD syndrome, where themajority of mutations are found in the amino N-SH2 domains. While this could account for a fraction of phenotypic variation seen in NS and overlap with theLEOPARDsyndrome, ourfindings indicate this does not necessarily extend toML in general. Reports of patients with non-cutaneous abnormalities of the LEOPARD syndrome have been described in families in which most members had cutaneous lentigines only *Correspondence to: Dr. Theresa R. Pacheco, M.D., Assistant Professor, Department of Dermatology & Cutaneous Oncology, B-153, 4200 E. Ninth Avenue, Denver, CO 80262. E-mail: theresa.pacheco@uchsc.edu

Use of a recombinant parvovirus to facilitate screening for human melanoma cell clones expressing tetracycline-responsive transactivators

The tetracycline regulatory (TET) system provides a useful means of controlling foreign gene expression in mammalian cells. Exploiting this system in cultured cells requires the prior isolation, from the cells of interest, of transfectant clones expressing the necessary TET transactivator, tTA, or reverse transactivator, rtTA. We describe a simple screening procedure for identifying transfectant clones expressing a properly regulated transactivator, and the application of this method to isolating clones of human melanoma cells expressing either tTA or rtTA. Clones in multi-well plates are transduced by exposure to a recombinant parvovirus containing a luciferase reporter, under control of a promoter responsive to the TET system transactivators. Transactivation of reporter expression in the presence or absence of doxycycline (DOXY) is determined after one to two days, using a rapid luciferase assay. Screening is easier and more reproducible with this transduction method than with conventional transient transfection of analogous reporter plasmids. Clones of two human melanoma cell lines showing >100-200-fold transactivation after transfection with either tTA or rtTA were readily identified using this method.