- [Show abstract] [Hide abstract] ABSTRACT: Background Immunotherapy based on the adoptive transfer of gene modified T cells is an emerging approach for the induction of tumor-specific immune responses. Memory stem T cells, due to their enhanced antitumor and self-renewal capacity, have become potential candidate for adoptive T cell therapy of cancer. Methods to generate memory stem T cells ex vivo rely on CD3/CD28 costimulation and the use of cytokines such as IL-7 and IL-15 during the entire culture period. However, a strong costimulation may induce differentiation of memory stem T cells to effector memory T cells. Here we show that manipulation of the length of the costimulation and addition of IL-21 enhance the ex vivo expansion of memory stem T cells. Methods Purified naïve T cells from healthy donors were cultured in the presence of anti-CD3/CD28 coated beads, IL-7, IL-15 and/or IL-21 (25 ng/ml). T cells phenotype from the different memory and effector subpopulations were analyzed by multiparametric flow cytometry. Results A short anti-CD3/CD28 costimulation of naïve T cells, combined with IL-7 and IL-15 significantly increased the frequencies of CD4+ and CD8+ memory stem T cells ex vivo, compared to a prolonged costimulation (34.6 ± 4.4 % vs 15.6 ± 4.24 % in CD4+; p = 0.008, and 20.5 ± 4.00 % vs 7.7 ± 2.53 % in CD8+; p = 0.02). Moreover, the addition of IL-21 to this condition further enhanced the enrichment and expansion of CD4+ and CD8+ memory stem T cells with an increase in the absolute numbers (0.7 × 106 ± 0.1 vs 0.26 × 106 ± 0.1 cells for CD4+; p = 0.002 and 1.1 × 106 ± 0.1 vs 0.27 × 106 ± 0.1 cells for CD8+; p = 0.0002; short + IL-21 vs long). Conclusions These new in vitro conditions increase the frequencies and expansion of memory stem T cells and may have relevant clinical implications for the generation of this memory T cell subset for adoptive cell therapy of patients with cancer.
- [Show abstract] [Hide abstract] ABSTRACT: Background/aims: Rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) every 14 days seems to achieve better outcomes than R-CHOP every 21 days in diffuse large B-cell lymphoma (DLBCL) patients. Currently, the standard regimen is R-CHOP every 21 days. Methods: This is a phase II clinical trial of treatment with 6 cycles of R-CHOP-14 with pegfilgrastim support in 2 populations of previously untreated DLBCL patients aged ≥65 years (n = 73) or <65 years (n = 51) with low-risk International Prognostic Index scores (0-2). Results: With a median follow-up of 63.7 months, the 5-year event-free survival rate was 53.8% in patients aged ≥65 years and 71.0% in patients aged <65 years. The 5-year overall survival rate was 71.4 and 89.8%, respectively. The complete remission rate was 69.9% for older and 80.4% for younger patients. The median relative dose intensity of cytotoxic drugs was 143.2% in the elderly and 149.1% in the young patients. Febrile neutropenia was the most common grade 3-4 adverse event, being higher in elderly patients (21.3 vs. 9.3%). Eight deaths (7 in elderly patients) were considered treatment related. Conclusion: In conclusion, the R-CHOP-14 regimen is feasible and very active, though it is more toxic in elderly patients mainly due to an increased incidence of infections. New strategies, such as new monoclonal antibodies or new targeted therapies, are needed to improve the outcomes of DLBCL patients.
- [Show abstract] [Hide abstract] ABSTRACT: The management of recurrent/refractory (R/R) Hodgkin lymphoma (HL) remains challenging. Previously published data have shown some efficacy of rituximab in this setting. The purpose of this phase II trial was to investigate the activity of ofatumumab in combination with etoposide, steroids, cytarabine and cisplatin (O-ESHAP) in 62 patients with R/R classical HL. Treatment consisted of ESHAP plus ofatumumab 1000 mg on days 1 and 8 of the first cycle and day 1 of the second and third cycles. O-ESHAP was well tolerated with only 3% of patients requiring treatment discontinuation because of adverse events. Overall response rate was 73% (44% complete metabolic response). In multivariate analysis, early relapse (P < 0·001), bulky disease (P < 0·001) and B symptoms (P < 0·001) were the most important prognostic factors for response. No failures of stem cell mobilization were observed. The high response rate, particularly the complete metabolic response rate, the low toxicity profile, and the high mobilizing potential of the O-ESHAP regimen suggest that patients with R/R HL may benefit from this salvage regimen. However, with the encouraging results observed with other new therapeutic agents in HL, the O-ESHAP regimen could be restricted to patients failing these agents or to those with R/R nodular lymphocyte-predominant HL.
- [Show abstract] [Hide abstract] ABSTRACT: Mycosis fungoides and Sézary syndrome (MF/SS) are the most common forms of primary cutaneous T cell lymphomas. We analyzed the applicability of the cutaneous lymphoma international prognostic index (CLIPi) in MF/SS. We introduced the total body-surface area affected (TBSA) and the type of skin lesions at diagnosis as prognostic variables. The overall survival (OS) at median time of follow up (96 months) was 75.6% (CI 95%, 62.0–98.5%). In the univariate analysis, age >60 years, advanced disease, type of skin lesions and TBSA >50 showed poorer OS (p < 0.05). In the multivariate analysis there was a significant increased relative risk of death in those patients >60 years, with advanced disease and TBSA >50% (p < 0.05). TBSA identified a group of poor prognosis patients with advanced MF/SS that may benefit from novel systemic therapies.
- [Show abstract] [Hide abstract] ABSTRACT: Sézary syndrome (SS) is characterized by rapidly progressive disease and poor survival. Although there is no standard treatment for SS, allogeneic stem cell transplantation (alloSCT) is the only treatment available that may offer a long survival. Alemtuzumab, a humanized monoclonal antibody that targets CD52, has reported some efficacy in this disease. To describe the experience with alemtuzumab treatment in patients with SS in our center. A total of 6 patients received alemtuzumab subcutaneously at different dosing regimens. The median time of follow-up after alemtuzumab was 6 months (range 3-29 months). The overall response rate (ORR) was 83.3% (5/6) with 66.7% complete responses (CR). The disease-free survival (DFS) at 6 months was 33.3%. Increased DFS was observed in patients undergoing an alloSCT after alemtuzumab treatment. The overall survival (OS) at 6 months was 60%. Alemtuzumab is an effective treatment in advanced MF/SS for palliation of symptoms and may be useful as a bridge therapy before alloSCT in relapsed/refractory patients.
- [Show abstract] [Hide abstract] ABSTRACT: In this issue of Blood, Zappasodi et al show that heat-shock protein 105 (HSP105/HSPH1) is preferentially expressed in aggressive B-cell lymphomas, it modulates BCL-6 and c-Myc expression, and its inhibition reduces the tumor growth in vivo, suggesting a novel target for aggressive B-cell lymphoma.1
- [Show abstract] [Hide abstract] ABSTRACT: Follicular lymphoma is a common type of non-Hodgkin's lymphoma observed in Western countries. The diagnosis of this disease is based primarily on morphological and immunohistochemical assessment. The proliferative index Ki67 correlates with histological grading and clinical aggressiveness. Currently, positron emission tomography/computed tomography scanning are not applied for standard staging at diagnosis of follicular lymphoma and its use is limited to those patients for whom the identification of residual disease is crucial for therapeutic decisions and only when transformation to a high-grade lymphoma is suspected. Our aim was to assess whether a correlation exists between the maximal standardized uptake value (SUVmax) at the biopsy site as detected via positron emission tomography/computed tomography and pathological (Ki67 and FL histological grade) and clinico-biological features (e.g. LDH, beta-2-microglobulin, Ann Arbor stage and FL International Prognostic Index - FLIPI) at diagnosis. We retrospectively identified 16 patients during the previous 3.5 years in whom node biopsies were guided, taking into account the SUVmax as detected upon PET/CT scan at diagnosis. The results of these biopsies were diagnostic of follicular lymphoma. We also included 6 patients with high grade B cell lymphoma: 5 diffuse large B cell lymphoma (DLBCL) and 1 FL 3b histological grade. A 2-tailed non-parametric Spearman's correlation analysis of the SUVmax with Ki67, histological grade, LDH and b-2-microglobuline was performed. The Ki67 (r = 0.73) and follicular lymphoma histological grade (r = 0.75) at the biopsy displayed a significant correlation with the SUVmax at diagnosis (p < 0.01). Our results suggest that SUV detected by positron emission tomography/computed tomography correlates with histological grade in follicular lymphoma/high grade B cell lymphoma, Ki67 and LDH. Positron emission tomography/computed tomography should be considered for guiding lymph node biopsy when transformation to a high-grade B cell lymphoma is suspected.
- [Show abstract] [Hide abstract] ABSTRACT: Non-Hodgkin lymphomas are among the most prevalent hematologic malignancies. Although the addition of rituximab (R) to chemotherapy has made a big impact in the treatment of B cell lymphomas, most of them are not cured yet. The panorama in natural killer/T cell lymphomas is more unsatisfactory, thus representing a group of diseases where effective therapies constitute an urgent medical need. In recent years, several new antineoplastic agents have been tested in clinical trials showing promising results. The aim of this review is to update information of these studies that are already changing the scenario of the treatment of patients with Non-Hodgkin lymphoma.
- [Show abstract] [Hide abstract] ABSTRACT: We monitored 133 high-risk allo-SCT recipients for 6 months after transplant for EBV reactivation by quantitative real-time PCR. Rituximab was given as pre-emptive therapy for viremia >1000 copies/mL. The 1-year cumulative incidence of EBV reactivation was 29.4% (95% confidence interval (CI): 18-40) in patients monitored due to initial high-risk characteristics (n=93) and 31.8% (95% CI: 19.7-44) in those followed because of the development of refractory GVHD (n=40). Overall response rate to Rituximab was 83%. Nine patients (9.6%) developed post-transplant lymphoproliferative disorder (PTLD) at a median of +62 days after SCT. Eight of them showed a concomitant CMV reactivation. Second SCT was the only risk factor associated with EBV infection and PTLD in multivariate analysis (hazard ratio (HR) 2.6 (95% CI: 1.1-6.4; P=0.04) and HR 6.4 (95%CI: 1.3-32; P=0.02)). The development of EBV reactivation was not associated with non-relapse mortality or OS (P=0.97 and P=0.84, respectively).Bone Marrow Transplantation advance online publication, 12 January 2015; doi:10.1038/bmt.2014.298.
- [Show abstract] [Hide abstract] ABSTRACT: We analyze the impact of cyclosporine (CsA) levels in the development of acute graft-versus-host disease (aGVHD) after reduced intensity conditioning allogeneic hematopoietic transplantation (allo-RIC). We retrospectively evaluated 156 consecutive patients who underwent HLA-identical sibling allo-RIC at our institution. CsA median blood levels in the 1st, 2nd, 3rd and 4th weeks after allo-RIC were 134 (range: 10-444), 219 (54-656), 253 (53-910) and 224 (30-699) ng/mL; 60%, 16%, 11% and 17% of the patients had median CsA blood levels below 150 ng/mL during these weeks. 53 patients developed grade 2-4 aGVHD for a cumulative incidence of 45% (95% CI 34-50%) at a median of 42 days. Low CsA levels on the 3rd week and sex-mismatch were associated with the development of GVHD. Risk factors for 1-year NRM and OS were advanced disease status (HR: 2.2, P = 0.02) and development of grade 2-4 aGVHD (HR: 2.5, P < 0.01), while there was a trend for higher NRM in patients with a low median CsA concentration on the 3rd week (P = 0.06). These results emphasize the relevance of sustaining adequate levels of blood CsA by close monitoring and dose adjustments, particularly when engraftment becomes evident. CsA adequate management will impact on long-term outcomes in the allo-RIC setting.
- [Show abstract] [Hide abstract] ABSTRACT: Focal adhesions have been associated with poor prognosis in multiple cancer types, but their prognostic value in diffuse large B-cell lymphoma (DLBCL) has not been evaluated. The aim of this study was to investigate the expression patterns and the prognostic value of focal adhesion proteins FAK, Pyk2, p130Cas and HEF1 in DLBCL. Focal adhesion proteins expression was examined using immunohistochemistry in normal lymphoid tissues and in 60 DLBCL patient sample sections. Kaplan-Meier survival and Cox regression analysis were performed to evaluate focal adhesion proteins correlation with patient prognosis. FAK, Pyk2, p130Cas and HEF1 expression was mostly found in the germinal centers of normal human lymphoid tissues. When assessed in DLBCL samples, FAK, Pyk2, p130Cas and HEF1 were highly expressed in 45, 34, 42, and 45% of the samples, respectively. The multivariate COX analysis revealed that decreased FAK expression was a significant independent factor predictive of poor disease outcome. FAK expression is an independent prognostic factor in DLBCL. Our results suggest that the addition of FAK immunostaining to the current immunohistochemical algorithms may facilitate risk stratification of diffuse large B cell lymphoma patients. This article is protected by copyright. All rights reserved.
- [Show abstract] [Hide abstract] ABSTRACT: Despite current advances in the treatment of cancer patients, a number of cancers remain incurable. The activation of the immune system as an approach to treat cancer has been a goal in oncology. A better understanding of the biology of cells involved in the immune response together with the knowledge of how tolerance and tumor immunosuppression regulates antitumor immune response has contributed to the development of improved cancer vaccines. In the last years, new strategies to enhance the immune response against cancer have been studied including antigen-pulsed dendritic cells, recombinant DNA and viral vaccines, genetically modified tumor cells, and a number of novel immune adjuvants targeting dendritic cells, T cells, and NK cells. In addition, targeting immunoregulatory cells and T cell inhibitory molecules with monoclonal antibodies is becoming a critical approach to enhance cancer vaccines in the clinical scenario.
- [Show abstract] [Hide abstract] ABSTRACT: The non-Hodgkin lymphomas are 12(th) most prevalent cancers in Europe. No recent update in the epidemiology of these lymphomas has been performed in our country. We diagnosed 701 new lymphomas during the period beginning January 1, 2000 and ending December 31, 2009 in our center. The most frequent lymphoma was diffuse large B cell lymphoma, followed by follicular lymphoma and then classic Hodgkin's disease. The male:female ratio is 1.2:1. Diagnosis by age showed that non-Hodgkin's lymphoma is by far more frequent in the 61-80 years old patients. On the other hand, classic Hodgkin's lymphoma is more frequent in the 20-40 years old population. Our results are very similar to those published by other centers in Europe and United States.
- [Show abstract] [Hide abstract] ABSTRACT: In the rituximab era, lymphoma patients with persistent disease receiving autologous transplantation have a very poor outcome. The addition of radioimmunotherapy to the conditioning regimen may improve outcome for these patients. We have evaluated, in a prospective phase 2 study, the safety and efficacy of the addition of 90Y-Ibritumomab tiuxetan to the conditioning chemotherapy in refractory diffuse large B cell lymphoma patients. Thirty patients with induction failure (primary refractory; n=18) or refractory to salvage immunochemotherapy at relapse (n=12) were included in the study. Patients with a median age of 53 years (range, 25-67) received 90Y-Ibritumomab tiuxetan at a fixed dose of 0.4mCi/kg (maximum dose 32mCi) 14 days prior to the preparative chemotherapy regimen. Histology included de novo diffuse large B cell lymphoma (22) and transformed diffuse large B cell lymphoma (8). All patients had persistent disease at the time of transplantation, with 25 patients considered to be chemorefractory. Median time to neutrophil recovery (>500/ml) was 11 days (9-21), and to platelet recovery (>20.000/ml) was 13 days (11-35). Overall response at day +100 was 70% (95% CI, 53.6-86.4) with 60% (95% CI, 42.5-77.5) complete responses. After a median follow-up of 31 months for alive patients (range, 16-54), estimated 3-year overall and progression-free survival is 63% (95% CI, 48-82) and 61% (95% CI, 45-80), respectively. We conclude that autologous transplantation with conditioning including 90Y-Ibritumomab tiuxetan is safe, and results in a very high response rate with promising survival in this very poor prognosis group of refractory diffuse large B cell lymphoma patients. Study registered at European Union Drug Regulating Authorities Clinical Trials (EudraCT) No. 2007-003198-22.
- [Show abstract] [Hide abstract] ABSTRACT: Strongyloides stercoralis is an intestinal nematode that causes strongyloidiasis, which affects 30 to 100 million people worldwide. Risk factors for hyperinfection and disseminated disease include immunosuppressive drug therapy, human T-lymphotropic virus-1 (HTLV-1) infection, solid organ and bone marrow transplantation, hematologic malignant diseases, hypogammaglobulinemia, and severe malnutrition and associated conditions. The diagnosis can be difficult because a single stool examination fails to detect larvae in up to 70% of the cases, and the symptoms are nonspecific. Although eosinophilia is a common finding in patients with chronic Strongyloides infection, it is an unreliable predictor of hyperinfection. Furthermore, the lack of eosinophilia while receiving immunosuppressive therapy cannot reliably exclude the underlying chronic Strongyloides infection. We report here a fatal Strongyloides hyperinfection in a patient receiving allogeneic stem cell transplantation; risk factors and outcome in this clinical setting are discussed.
- [Show abstract] [Hide abstract] ABSTRACT: We have previously reported that LITAF is silenced by promoter hypermethylation in germinal centre-derived B-cell lymphomas, but beyond these data the regulation and function of lipopolysaccharide-induced tumour necrosis factor (TNF) factor (LITAF) in B cells are unknown. Gene expression and immunohistochemical studies revealed that LITAF and BCL6 show opposite expression in tonsil B-cell subpopulations and B-cell lymphomas, suggesting that BCL6 may regulate LITAF expression. Accordingly, BCL6 silencing increased LITAF expression, and chromatin immunoprecipitation and luciferase reporter assays demonstrated a direct transcriptional repression of LITAF by BCL6. Gain- and loss-of-function experiments in different B-cell lymphoma cell lines revealed that, in contrast to its function in monocytes, LITAF does not induce lipopolysaccharide-mediated TNF secretion in B cells. However, gene expression microarrays defined a LITAF-related transcriptional signature containing genes regulating autophagy, including MAP1LC3B (LC3B). In addition, immunofluorescence analysis co-localized LITAF with autophagosomes, further suggesting a possible role in autophagy modulation. Accordingly, ectopic LITAF expression in B-cell lymphoma cells enhanced autophagy responses to starvation, which were impaired upon LITAF silencing. Our results indicate that the BCL6-mediated transcriptional repression of LITAF may inhibit autophagy in B cells during the germinal centre reaction, and suggest that the constitutive repression of autophagy responses in BCL6-driven lymphomas may contribute to lymphomagenesis.
- [Show abstract] [Hide abstract] ABSTRACT: MYC alterations influence the survival of patients with diffuse large B-cell lymphoma. Most studies have focused on MYC translocations but there is little information regarding the impact of numerical alterations and protein expression. We analyzed the genetic alterations and protein expression of MYC, BCL2, BCL6, and MALT1 in 219 diffuse large B-cell lymphomas. MYC rearrangement occurred as the sole abnormality (MYC single-hit) in 3% of cases, MYC and concurrent BCL2 and/or BCL6 rearrangements (MYC double/triple-hit) in 4%, MYC amplifications in 2% and MYC gains in 19%. MYC single-hit, MYC double/triple-hit and MYC amplifications, but not MYC gains or other gene rearrangements, were associated with unfavorable progression free survival and overall survival. MYC protein expression, evaluated using a computerized image analysis, captured the unfavorable prognosis of MYC translocations/amplifications and identified an additional subset of patients without gene alterations but with similar poor prognosis. Tumors expressing both MYC/BCL2 had the worst prognosis, whereas double negative tumors had the best outcome. High MYC expression was associated with shorter overall survival irrespective of the International Prognostic Index and BCL2 expression. In conclusion, MYC protein expression identifies a subset of diffuse large B-cell lymphoma with very poor prognosis independently of gene alterations and other prognostic parameters.
- [Show abstract] [Hide abstract] ABSTRACT: Refractory acute graft-versus-host disease (aGVHD) remains an important cause of mortality after allogeneic stem cell transplantation. No standard therapy exists once steroids fail to obtain a good response. In 2006, our group published a series of patients who received inolimomab, an anti-interleukin-2 receptor monoclonal antibody, as salvage therapy with initial encouraging results. In this update, we have analysed a larger group of patients with prolonged follow-up. Ninety-two consecutive patients were treated with inolimomab in our center between April 1999 and December 2011. Overall response rate was 42% (complete response [CR] in 14%) on day +30. Predictors of failure to respond in the multivariate analysis were overall aGVHD grade IV, instauration of inolimomab before day 15 of aGVHD diagnosis and severe lymphopenia. Patients without gastrointestinal (GI) involvement appeared to do better, with a 70% response rate compared with 39% in patients with GI involvement (p=0.06). However, the 2-year overall survival (OS) was 18% (95% CI 10-26%) for the entire cohort and 33% (95% CI 25-40%) for day-30 responders. Acute GVHD was the main cause of death (49%) followed by opportunistic infections (27%). In conclusion, results of this update show that although inolimomab is a well tolerated drug with a moderate number of short term responses, it is associated with long-term survival in only one third of responding patients. These data highlight the need of investigating new rescue treatments with sustained effect and theimportance of reportinglong-term outcomesin GVHD studies.
Hospital de la Santa Creu i Sant Pau
Barcino, Catalonia, Spain
- Hematology Clinic Services
Hospital Universitario de SalamancaHelmantica, Castille and León, Spain