A phase I study of the anti-natural killer inhibitory receptor (KIR) monoclonal antibody (1–7F9, IPH2101) in elderly patients with acute myeloid leukemia (AML)

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Background: The outcome of the majority of patients with AML remains poor, especially in the oldest patients. Allogeneic SCT is a curative approach for AML. In some models, it has been shown that KIR mismatch is important for the anti-leukemic effect of the graft, most probably through unleashed NK cells towards AML blasts, as suggested by enhanced in vitro NK lytic activity of KIR-HLA mismatched donor NK against recipient blasts. To mimic this effect with a pharmaceutical agent, a fully human IgG4 anti-KIR mAb specific for KIR2DL1/2/3 (HLA-C specific KIRs) was generated. We present the results of the first-in-human phase I trial of this agent in patients with AML in complete remission (CR). Methods: Patients aged 60–80 years with non promyelocytic AML in first CR following induction and 1–6 cycles of consolidation chemotherapy, normal renal, and hepatic functions, KIR-expression on patient NK-cells and who signed informed consent were eligible.Dose escalation (0.0003, 0.003, 0.015, 0.075, 0.3, 1, 3 mg/kg) was studied using a 3+3 scheme. Pharmacokinetic (PK) and circulating cytokines (MIP1β, TNF) were measured by ELISA. KIR occupancy and activation markers (CD69) were monitored by flow cytometry. Results: To date, inclusion has been completed until 1mg/kg cohort. Data of the first 15 patients (end of 0.3 mg/kg cohort) are available. No dose limiting toxicity has been observed. Side effects that could be related to drug administration were mild and transient. The first dose level resulted in a transient KIR occupancy ranging from 20 to 50%. PK values were then in line with modelling data, resulting at 0.3 mg/kg in a Cmax= 6350 ± 504 ng/mL, >80% KIR saturation for one week, and desaturation in the following week. As expected for an IgG4, NK cell numbers were unaffected by the treatment. Upregulation of CD69 on NK cells and concomitant increases in TNF and MIP1b circulating cytokines were observed in some patients at the highest doses (0.075, 0.1, 0.3 mg/kg) but a dose dependency has not been reached yet. Conclusions: Anti-KIR treatment is safe and well tolerated to date. At the 0.3mg/kg dose, MTD has not been reached, but a one week receptor blockade and signs of NK activation were observed.

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A phase II study of bortezomib in combination with intensified CHOP-like regimen (ACVBP) in patients with previously untreated T-cell lymphoma: Results of the GELA LNH05–1T trial

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Background: Patients with peripheral T/NK cell lymphomas (PTCL) still have a dismal prognosis with 5-yr survival less than 30% in most cases. No alternative regimen has been proven superior to CHOP so far. This multicenter phase II study was carried out to assess efficacy and safety of bortezomib in combination with an intensified CHOP-like regimen. Methods: Pts aged 18 to 65 yrs with previously untreated PTCL were planned to receive 4 bi-monthly cycles of ACVBP (doxorubicine 75 mg/m2 D1, cyclophosphamide 1200 mg/m2 D1, vindesine 2 mg/m2 D1 and D5, bleomycine 10 mg D1 and D5 and prednisone D1 to D5) followed by a sequential consolidation consisting of HD methotrexate (2 courses), etoposide + ifosfamide (4 courses) and cytarabine (2 courses) at 2 weeks intervals. Bortezomib 1.5 mg/m2 was administered at D1 and D5 of each ACVBP cycle, and then at D1, D8 and D15 every 4 weeks during consolidation phase for a total of 20 injections during the whole treatment. Results: 57 eligible pts (M 38, F 19, median age 52.5 yrs) with mostly AITL and PTCL NOS subtypes were enrolled between January 2006 and November 2007; 78% had stage III-IV disease and 53% had aaIPI ≥ 2. Forty six pts (81%) have completed induction treatment with ACVBP and only 28 (49%) the consolidation phase, mainly for disease progression. The CR + CRu rate was 45% after induction and 46% after consolidation. As of November 14th, 2008, 22 pts (39%) have died, mostly from lymphoma. The median percentage of planned dose of bortezomib received was 98% during ACVBP induction where the vinca alkaloid used was vindesine, and ranged from 90 to 95% during the consolidation courses. The dose intensity of bortezomib was 84.3% during induction, similar to that of doxorubicine and cyclophosphamide. Thrombocytopenia was more pronounced than previously observed with ACVBP alone but no life-threatening hemorrhagic event occurred. Conclusions: The combination of bortezomib with ACVBP is feasible without neurological or platelet unexpected toxicities. The response rate of such a regimen in PTCL does not appear higher than previously observed with ACVBP alone in our historical cohort.

No significant financial relationships to disclose.

L-asparaginase-based treatment of 15 western patients with extranodal NK/T-cell lymphoma and leukemia and a review of the literature

BACKGROUND

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, and aggressive NK-cell leukemia are highly aggressive diseases with a poor outcome.

PATIENTS AND METHODS

We report a multicentric French retrospective study of 15 patients with relapsed, refractory, or disseminated disease, treated with L-asparaginase-containing regimens in seven French centers. Thirteen patients were in relapse and/or refractory and 10 patients were at stage IV.

RESULTS

All but two of the patients had an objective response to L-asparaginase-based treatment. Seven patients reached complete remission and only two relapsed.

CONCLUSION

These data, although retrospective, confirm the excellent activity of L-asparaginase-containing regimens in refractory extranodal NK/T-cell lymphoma and aggressive NK-cell leukemia. Therefore, L-asparaginase-based regimen should be considered as a salvage treatment, especially for patients with disseminated disease. First-line L-asparaginase combination therapy for extranodal NK/T-cell lymphoma and aggressive NK-cell leukemia should be tested in prospective trials.

Long-term results of the GELA study comparing R-CHOP and CHOP chemotherapy in older patients with diffuse large B-cell lymphoma show good survival in poor-risk patients

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Background: The prospective randomized study LNH-98.5 was first reported in the N Engl J Med and J Clin Oncol with a median follow-up of 2 and 5 years. Here, we present the 7-year follow-up of the 399 patients included in the study. Methods: Patients had untreated diffuse large B-cell lymphoma and were 60 to 80 years old with a median age at diagnosis of 69 years. 60% had a poor risk lymphoma as defined by the aaIPI risk score of 2 or 3. 197 patients were randomized in CHOP arm and 202 in R-CHOP arm. Treatment consisted of 8 cycles of CHOP every 3 weeks with rituximab the same day in R-CHOP. Results: With a median follow-up of 7.1 years, 76% of the patients had an event in CHOP compared to 58% in R-CHOP, p=0.0002 ( Table ). 65% of patients died in CHOP arm compared to 47% in R-CHOP arm: 80% and 71% of them from lymphoma or treatment toxicity, 5% and 5% from another cancer, and 15% and 22% in CR from other causes, respectively. Survival curves show the same difference as reported before with a large difference in favour of R-CHOP ( Table ). Patients not expressing bcl-2 protein treated with R-CHOP have a statistically longer PFS but only a trend for OS because they responded better to salvage treatment. No statistically significant difference was observed for patients <70, 70–74, or ≥75 years old. Patients treated with R-CHOP have good survival even with poor risk parameters: 43% are alive for age ≥75 years, 38% for PS=2, 54% for B symptoms, 47% for stage IV, 45% for high LDH level, 54% for Hb ≤10 g/dl, and 42% for high aaIPI score. Death in CR was associated with high risk aaIPI score and presence of other diseases before lymphoma diagnosis. Conclusions: This analysis confirms the long term benefit associated with the combination of rituximab and CHOP and shows that older patients must be treated as younger patients even in presence of high risk characteristics or concomitant diseases.

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