8556 Background: No salvage regimen has shown clear superiority in relapsed NHL. Bendamustine has single agent activity in relapsed aggressive NHL. We conducted a phase I trial using a novel RICE-like salvage regimen in which ofatumumab was substituted for rituximab and bendamustine replaced ifosfamide, combined with carboplatin and etoposide (BOCE) Methods: Patients (pts) with relapsed or refractory aggressive B NHL were eligible. The design was a standard 3+3 design using escalating doses of bendamustine [70, 90, and 120 mg/m2 D1-2] with ofatumumab (cycle 1: 300 mg D1, 1000 mg D3, cycle 2 and 3: 1000 mg D1), carboplatin AUC 5 D2 and etoposide 100mg/m2 D1-3. Results: Eleven pts were enrolled (7M/4F). Median age was 62 (range 53-75), 5 pts (45%) had diffuse large B NHL, 4 pts (36%) had grade 3 follicular NHL, 1 pt (9%) had mantle cell NHL, and 1 pt (9%) had transformed CLL. Five pts (46%) had refractory disease and 6 pts (56%) had relapsed disease. All pts with refractory disease were refractory to rituxi...

Background The detection of skeletal metastasis, enlarged lymph nodes or parenchymal lesions in patients (pts) with established solid tumors most commonly denotes advanced stage disease. If not confirmed histologically, a subset of pts might be over staged and mismanaged palliatively.Methods We report 7 cases of low-grade B cell lymphomas diagnosed in a bone, lymph node or lung biopsy during staging workup in patients with suspected metastatic solid tumors.Results All pts were men aged 41 to 80 yo diagnosed with: non-small cell lung (NSCL), prostate, lip squamous cell, bladder, renal cell cancer (CA) and nasal adenoid cystic carcinoma. Imaging studies done during initial workup or follow up after resection of the primary tumor revealed bone metastasis, lymphadenopathy or lung nodules suggesting advanced stage of the primary CA. Invasive workup of the lesions in question revealed incidental low-grade B cell lymphomas (2 low grade lymphomas of bone, 2 CLL/SLL, 1 BALT, 1 marginal zone and 1 nodular lymphocyte predominant Hodgkin lymphoma). In all cases, this led to down staging and changed the management of the solid CA. Surgical resection of the tumor was done after it was down staged from non-resectable to resectable in 2 pts with head/neck CA; 1 pt with NSCL was down staged from stage IV to IIIA and received chemo/radiotherapy; 1 pt with prostate CA was down staged from stage IV to I; 3 pts were down staged from stage IV and were in remission from previously resected solid tumors. Only 2 pts required therapy for the newly diagnosed lymphoma. Avidity of the lesions revealed SUV ranging from 1.28 to 14.11 in the bone and from 2.17 to 6.98 in the lymph nodes.Conclusions Accurate staging of pts with solid tumors is critical in defining optimal goals of therapy. The growing use of PET/CT scans results in a higher rate of incidentally detected bone lesions or lymphadenopathy. Whereas a number of solid tumors readily spread to bone and lymph nodes, a spectrum of indolent lymphoid disorders may coexist in pts with established solid tumors. These lymphomas may remain asymptomatic for years. This might be misinterpreted as advanced stage solid tumor unless confirmed histologically.Disclosures: No relevant conflicts of interest to declare.

Abstract Abstract 143 Background: Mammalian target of rapamycin (mTOR) inhibitors enhance cytotoxic chemotherapy effects in primary acute leukemia cells in preclinical assays. This prompted a multi-center evaluation of a combination of mTOR inhibitor plus induction chemotherapy in AML. As mTOR is frequently but not uniformly activated in primary AML samples, it is unclear which patients benefit from this targeted approach. Thus, we sought to monitor mTOR kinase activity during therapy to determine whether target activation and/or inhibition predicted clinical response. We previously reported our preliminary experience monitoring pS6 in AML blasts by flow during clinical trials combining sirolimus and AML induction chemotherapy (Kasner et al, ASH 2011, #230). Here we provide the final clinical and pharmacodynamic results from this cohort of subjects. Methods: Subjects had relapsed/refractory AML or untreated AML with unfavorable risk factors (e.g. therapy-related, prior MDS or MPN, or age >60 without favorable karyotype) with a median age of 60.5 years (range 32–77). Subjects received oral sirolimus (12 mg on day 1, then 4 mg daily on days 2–9) plus MEC (mitoxantrone 8 mg/m2/day, etoposide 100 mg/m2/day, cytarabine 1 gm/m2/d on days 4–8) on one of two successive clinical trials. Clinical response was assessed at hematologic recovery or day 42 using IWG criteria (CR, CRp, PR vs. non-response). Pharmacodynamic samples were collected from blood or marrow at baseline, 2 hours post-sirolimus dose on days 1 and 4, and at trough on day 4 (prior to chemotherapy administration). Concurrent blood rapamycin concentration was measured by immunoassay or HPLC. Whole blood/marrow fixation was performed using published methods (Perl, et al. Clin. Cancer Res. 2012). Positive gates for pS6 were created by comparing blasts in ex vivo stimulated (phorbol ester/PMA) and inhibited (rapamycin) conditions and/or autofluorescence (FMO) controls. Results: We enrolled 52 subjects in 2 consecutive trials; 51 were evaluable for clinical response. Toxicity was similar to published MEC data. 3 infectious deaths occurred (6%). Prolonged aplasia was not observed. 24/51 (47%) subjects responded, with 18 CR (35%), 1 CRp, and 5 PR's observed. Mean peak and trough rapamycin concentrations on day 4 were 22.0 and 8.9 ng/ml, respectively, and did not differ among clinically responding or non-responding subjects. Median survival time for the whole group was 243 days (longest follow up 1584 days). Among the 24 subjects achieving CR or PR, median duration of time to the first event (relapse or death) was 261 days. 20 subjects were able to proceed to a stem cell transplant following therapy. Serial flow cytometric analysis was performed in 46 subjects, of which 37 provided paired day 1 and day 4 flow samples and were evaluable for clinical response at count recovery. The overall response rate (ORR) among subjects with baseline constitutive pS6 was 14/27 (52%, 9 CR, 1 CRp, 4 PR). The ORR for subjects without constitutive pS6 was 4/10 (40%, 3 CR, 1 PR). Subjects with >50% reduction in pS6 positive blasts on day 4 were considered to be biochemically sensitive to rapamycin, while subjects with <50% reduction or increased pS6 were considered rapamycin-resistant. Categorizing subjects based upon the achievement of CR/CRp/PR vs. NR, the reduction in blasts' pS6 percent on day 4 was 72% among clinically responding subjects and 43% among those without clinical response. The ORR in rapamycin sensitive patients was 10/15 (67%, 6 CR, 4 PR, 5 NR), while in resistant subjects was 4/12 (33%, 3 CR, 1 CRp, 8 NR). Combining rapamycin resistant subjects and those with no basal pS6, the ORR was 8/22 (36%, 6 CR, 1 CRp, 1 PR, 14 NR). Conclusions: Sirolimus plus MEC is a tolerable and active regimen for patients with high risk AML. The addition of an mTOR inhibitor augmented chemotherapy response particularly among those with demonstrable baseline mTOR activation and target inhibition during therapy. These results demonstrate the diversity of AML with reference to the activation of ribosomal S6 and suggest that phospho-flow monitoring may be an effective tool for patient selection for use of signaling inhibitors in AML. Future trials of this regimen may benefit from enrichment for subjects with mTOR activation and/or rapamycin sensitivity assessment. Disclosures: Off Label Use: Rapamycin. FDA approved for solid organ transplant. Investigational use for treatment of leukemia. Weiss:Celgene: Consultancy.

Abstract Abstract 2531 DNA repair and repair-related genes encode molecules that function as critical guardians of the genome, both in terms of chromosome stability and single base integrity. Defects in such functions, both inherited and acquired, represent key factors that contribute to the etiology of cancer (e.g., RB1, TP53 and ATM). Copy number alterations (CNAs) in such genes have been described for one or more hematologic malignancies and disease-specific testing is routinely employed for the detection of these important diagnostic/prognostic markers. Additional DNA repair genes have been implicated as potential factors influencing the onset, progression, and/or chemo-resistance of disease. In the present study, we analyzed 155 DNA repair/repair-related genes for CNAs in 425 cases of hematologic malignancy using microarray analysis. Cases represented nine distinct clinical entities with at least 30 cases per entity. Disorders represented include myelodysplastic syndrome (MDS), chronic lymphocytic leukemia (CLL), myeloproliferative neoplasm (MPN), chronic myeloid leukemia (CML), B-cell and T-cell acute lymphoblastic leukemia (B-ALL, T-ALL), acute myeloid leukemia (AML), non-Hodgkin lymphoma (NHL), and multiple myeloma (MM). An oligo-based microarray platform was employed with higher density coverage for the DNA repair/ repair-related genes (1 probe/0.2–7.0 kb). Results were assessed relative to multiple databases of known benign variation. A proof of principal analysis included RB1, TP53 and ATM, for which genomic alterations and disease preference have been well established. Analysis of RB1 revealed CNAs in 74 cases (4 gains and 70 losses) (17.4% of total) with copy gains uniformly attributable to trisomy 13 in cases of B-ALL. As expected, loss of RB1 typically reflected either monosomy 13 (31/70 seen predominately in MM) or smaller deletions (∼1 Mb, seen in CLL). CNAs in TP53 included 2 gains and 42 losses (10.4% of total), with gains again related to trisomy (exclusively hyperdiploid B-ALL), whereas deletions varied in size and disease association. CNAs in the ATM included 28 gains and 19 losses (11.1% of total). Gains reflecting trisomy correlated with diverse diagnoses, while more focal gains (∼10 Mb) were seen exclusively in B-ALL (3 cases). Not surprisingly, small losses of ATM (<10 Mb) occurred almost exclusively in CLL. Thus, microarray findings for these classic tumor suppressor genes correlated well with disease specificity for alterations submicroscopic in size (<10 Mb). An additional 152 DNA repair/repair-related genes were analyzed and a number of genes showed disease-specific correlations for submicroscopic CNAs. For example, deletion of ERCC5 was seen in B-ALL (2 cases); however, co-deletion of ERCC5 and LIG4 was confined to NHL (3 cases). Smaller deletions involving a number of other genes also occurred specifically in NHL (GTF2H4, POLQ, REV1L, FANCL, BRCA2, and NUDT1). While abnormalities in TERT were infrequent (21 gains and 4 losses) and nearly always associated with aneuploidy, an intragenic duplication of three exons was seen in a single case of diffuse large B-cell lymphoma with a history of failed therapy. Regarding AML, deletion of UBE2V2 was seen in a case exhibiting numerous multi-megabase amplifications, a potential consequence of dysregulated DNA replication. AML-specific CNAs include deletions of RPA2 that always associated with translocation-positive cases (PML/RARA; MLL/MLLT3; MLL/MLLT4), and deletions of APTX (reduced expression correlates with favorable therapy response), as well as an intronic duplication within MGMT (therapy resistance associates with overexpression). Smaller CNAs involving ALKBH3 were seen specifically in MM (3 cases), while deletions of ALKBH5 impacting nearby TOP3A were seen in MDS (2 cases). Additional genes in which recurrent CNAs were associated with multiple disorders included NEIL1, PMS2, ENDOV, CHEK2, and HELQ. The data reveal CNAs in DNA repair and repair related genes; many are recurrent abnormalities that exhibit disease specificity. The findings are consistent with previous data addressing biological function, disease progression and response to therapy. Further study is warranted to validate these alterations as diagnostic/prognostic biomarkers or as predictive biomarkers useful in directing more personalized treatment decisions. They may also represent potential new targets for therapy. Disclosures: Schultz: Signature Genomic Laboratories, PerkinElmer Inc.: Employment. McDaniel:Signature Genomic Laboratories, PerkinElmer Inc.: Employment. Shaffer:Signature Genomic Laboratories, PerkinElmer Inc.: Employment, Equity Ownership. Ballif:Signature Genomic Laboratories, PerkinElmer Inc.: Employment, Equity Ownership.

Chronic myeloid leukemia (CML) rarely develops following organ transplantation. Chronic immunosuppressive therapy is believed to be responsible for secondary malignancies, mainly the tumors of the lymphoid tissue and skin neoplasms.1-3 The known mechanisms involved in the development of secondary malignancies include decreased immunosurveillance due to chronic immunosuppression and direct tumorigenic effect of the immunosuppressive medications. Little is known yet of the factors that may predispose transplant recipients to secondary myeloproliferative disorders. Epstein-Barr virus reactivation, which plays a key role in post-transplant lymphoproliferative disorders (PTLD), has no known impact on secondary CML. Similarly, whereas the association between the more prevalent PTLD and the type of an immunosuppressive regimen used has been well established, the factors involved in secondary CML are yet to be identified. There are different ways to achieve immunosuppression to prevent organ rejection, and tacrolimus has recently emerged as the favorite immunosuppressive medications. Yet, little is known about the long-term effects of tacrolimus on immune surveillance. Here we present the first reported case of CML, which developed post–heart transplantation in a patient treated with tacrolimus and mycophenolate mofetil.

Abstract 3529 Hematologic malignancies in older patients are often characterized by resistant phenotypes which would ideally be treated by allogeneic hematopoietic stem cell transplant (HSCT). However, allogeneic HSCT in this age group is associated with greater regimen-related toxicity than in younger patients limiting its application. In addition, older patients have a smaller matched related donor pool due to the age and comorbidities of their siblings, but often have haploidentical offspring donor options. In order to extend the application of HSCT to older patients (>66), we developed a reduced intensity regimen utilizing haploidentical donors. In this approach, donor T cells and CD 34+ cells are infused at 2 separate times so that the dose and timing of each cell type can be independently controlled. This “break apart” method allows the tolerization of donor T cells by cyclophosphamide (CY) without exposure of the donor HSCs to the drug. Seventeen patients ages 66–77 with AML (9), advanced MDS (2), biphenotypic leukemia (1), CLL (2), NHL (2), and myelofibrosis (1) were treated. All but 2 patients had persistent disease at the time of HSCT. Ten of 17 had a Karnofsky Performance Score (KPS) of >90%, while 7 patients9 KPS was 70–80%. The hematopoietic cell transplantation comorbidity index (HCT CI) for the group was between 0 and 5 points. Time from first treatment to HSCT was widely variable. The patients received fludarabine 30 mg/m2/d and cytarabine 2 Gms/m2/d on days -11 through -8. Thiotepa 5 mg/m2/d on days -11 to -9 was substituted for cytarabine in patients with active myeloid malignancies at HSCT. TBI (2 Gy) was given on d-6 immediately followed by 2 ×10e8/kg of the donor9s T cells (DLI step). This T cell dose was associated with consistent engraftment and acceptable rates of GVHD in our prior studies. CY 60 mg/kg/d was given on days -3 and -2. A CD34 selected donor product was infused on day 0 (HSC step). T cells were collected from the donors prior to the start of G-CSF for stem cell mobilization. Mycophenolate Mofetil and Tacrolimus were started on d-1. All patients received the targeted T cell dose of 2×10e8 cells/kg, and within 24 hours developed fevers (median peak temperature 103.8f), and in many cases diarrhea and rash. All of the symptoms from this alloreaction resolved after the 2 nd dose of CY. The median CD34+/kg dose was 3.34 × 10e6/kg (range 1.4–8.94 × 10e6/kg). The median amount of residual (non-tolerized) T cells in the HSC product was 0.24 × 10e4/kg (range 0.03–4.5 × 10e4/kg). One patient developed hypotension during the alloreaction requiring steroids. There were no other unexpected infusion-related reactions. Five patients developed decreases in ejection fraction (EF), not always associated with clinical heart failure, and 5 patients developed atrial dysrhythmias. Two early deaths occurred from sepsis and decreased EF on days +2 and +11, both in patients with KPS of 70–80% but with HCT-CI scores of 90% at transplant and all surviving patients had HCT CI scores of 3 have died. The only 2 patients without active disease at HSCT are both alive, 19 and 26 months post HSCT. Except for the most recently treated patient who is not yet evaluable, all of these older patients have resumed their baseline activities of daily living. Haploidentical RIC using this 2 Step protocol is a viable treatment option for older adults. Rates of significant GVHD were acceptable and the majority of patients were able to tolerate the transplant procedures and be discharged to their homes. Based on the outcomes of this small group of patients, this type of therapy should be offered to fit senior adults with a low co-morbidity index especially if they have achieved a complete remission with up front therapy but are at high risk for relapse in the absence of HSCT. Disclosures: No relevant conflicts of interest to declare.

Pediatric nodal marginal zone lymphoma (NMZL) is described as a separate variant of NMZL in the most recent WHO classification of tumors of hematologic and lymphoid tissues. It has distinctive morphology and clinical presentation and stands out as an indolent disease with remarkably better overall prognosis compared to classic NMZL. Here we report two adult patients with NMZL with clinical and morphologic features consistent with pediatric NMZL (pNMZL) and review available literature describing the clinical and histologic presentation of pNMZL. Two men, ages 44 and 18 years, each presented with localized cervical lymphadenopathy, both demonstrated florid proliferation of the marginal zone and disruption of reactive germinal centers, progressive transformation of germinal centers-like morphologic features typical for pNMZL and clonal disease with immunophenotype consistent with NMZL. This is the first report of pNMZL in a middle-aged person. Distinct histologic features and characteristic benign clinical course will help to distinguish this rare variant from other NMZL in the adults. Clinically, recognition is important to understand the true incidence of this rare form in the adult population and to avoid unnecessary overtreatment of this indolent form.

Abstract Abstract 2192 Bortezomib is a proteasome inhibitor known to affect multiple signaling pathways., The inhibition of nuclear factor KB (NF-KB) activation and the induction of apoptosis in cells that over-express bcl-2 have been implicated as an important mechanism of action in hematologic malignancies. The combination of mitoxantrone and etoposide has been successful in relapsed/refractory acute myeloid leukemia with complete remission (CR) rates of 35–45%, with median duration of CR of 4–5 months. Based on the ability to inhibit NF-KB, the addition of bortezomib to this regimen should render malignant cells more susceptible to mitoxantrone and etoposide. Patients with relapsed or refractory acute myeloid or lymphoid leukemia were offered enrollment on a phase I-II dose escalation study of bortezomib (0.7, 1.0, or 1.3 mg/m2) on days 1 and 4 in combination with mitoxantrone 10 mg/m2 days 1–5 and etoposide 100 mg/m2 days 1–5. Dose escalation was allowed if no patient in the previous cohort had dose limiting toxicity defined as > grade 3 toxicity definitely related to study drug. The phase 1 portion of the study was completed in late 2007 and reported at ASCO 2008. The phase 2 portion enrolled using a bortezomib dose of 1.3 mg/m2. To date the phase 2 portion has reached a pre-planned stopping point and enrolled 25 patients of whom 22 received therapy and are evaluable (1 patient enrolled but was found to be ineligible prior to starting therapy, 2 signed consent and subsequently refused therapy). The median age of patients on the phase 2 portion is 53 (range 32–76; 9 of 22 were age 60 or greater). Five patients had a diagnosis of Acute Lymphoblastic Leukemia (ALL); 17 had Acute Myeloid Leukemia (AML). The median number of prior therapies is 2, although several patients had multiple cycles of prior therapies and 5 had had prior allogeneic stem cell transplants. There were 13 female and 9 male subjects. Toxicity has been tolerable; one patient with history of prior stem cell transplant developed congestive heart failure presumed secondary to therapy which subsequently improved with medical management. One patient with a history of prior intubation developed respiratory distress from tracheal stenosis (likely unrelated to therapy). One patient had a CNS bleed and three had admissions for febrile neutropenia. Other patients developed febrile neutropenia but were not scored as Serious Adverse Events as the febrile neutropenia occurred while hospitalized and therefore did not require admission. Patients were required to have a marrow aspirate at the nadir of their blood counts (approximately day 14) marrow aspirate and a recovery marrow aspirate to evaluate response. Eight of 22 patients (36.4%) had a response to therapy. This includes 2 who achieved a morphologic leukemia free state but who did not achieve full count recovery prior to the next therapy and 6 who achieved morphologic complete remission. This included 2 of the 5 (40%) patients with ALL and 6 of the 17 (35.3%) with AML. Ten patients subsequently underwent allogeneic stem cell transplant (1 unrelated donor, 8 haploidentical donors, one matched sibling donor). This included 5 patients who did not have a complete response to therapy, but had either stable disease or a reduction in leukemic burden after the study therapy. 8 of 22 (36.4%) are alive at a median of 121 days (range 53–277 days) following initiation of therapy. Fourteen of 22 patients expired at a median of 127 days (range 31–842) following initiation of therapy. Causes of death include relapse or progression of primary disease (n=10), complications of therapy/ cytopenias (n=2) and complications of stem cell transplant (n=2). The combination of bortezomib, mitoxantrone and etoposide was well tolerated in this study, and the ability of bortezomib to enhance the effects of other cytotoxic agents may result in increased efficacy as well. The Phase 2 portion has reached the pre-planned evaluation point and the regimen has demonstrated reasonable efficacy in a heavily pre-treated patient population. The primary endpoint was disease status on recovery from study therapy (approximately day 28), with a treatment goal of moving patients to allogeneic stem cell transplant rapidly. Based on the interim analysis the study will accrue to a targeted enrolment of 44 patients. Disclosures: Off Label Use: The use of bortezomib in acute leukemias is off label but is studied in the presented research as a way to potentiate the other therapeutic agents.

Abstract Abstract 5012 Identical twins are an excellent model in which to study tumor-specific immune responses (Gitelson et al Br J Haem 2002) as it can be postulated that the immune systems are identical. Spontaneous remissions in FL occur but the immunologic mechanisms remain elusive. We investigated adaptive and innate immunologic phenotypes and responses in a 41-year old patient with untreated grade 1 FL, and her healthy identical twin sister. Patients and methods The patient has had a waxing and waning course of FL over 7 years and currently is in spontaneous partial remission (> 50% reduction of generalized lymphadenopathy) and her peripheral blood was negative for t(14:18) by PCR at the time of this analysis. Immunologic responses of her twin, as well as another set of healthy identical twin sisters, were investigated as controls. We studied peripheral blood using 8-color multiparametric flow cytometry for frequencies and phenotypes of NK and regulatory T cells (Tregs). FOXP3+ cells were further analyzed for naïve, central memory and effector memory phenotype. Activation of NK cells and degranulation in response to tumor target cells as measured by Lysosomal-Associated Membrane Protein 1 (LAMP-1) surface expression were investigated. An erythroblastoid cell line (K562) and an EBV transformed MHC-I deficient lymphoblastoid cell line (721.221) were used as targets. Results NK studies revealed that activated CD69+ NK cells were increased in percentage in FL patient (4.43%) compared to her healthy twin (1.82%), and had increased mean fluorescence intensity (MFI) of 1057 vs 357, respectively. In contrast, almost identical frequencies and MFI of activated NK cells were found in the set of healthy twins (0.55% vs 0.54% and 153 vs 153, respectively). NK cells of FL patient exhibited elevated degranulation compared to the healthy twin in response to stimulation by either target cell: LAMP-1 staining MFI 1907 vs 1395, respectively for 721.221 target cells and 1394 vs 1122, respectively for K562 cells, whereas no difference was detected in non-stimulated NK cells (MFI 536 vs 506, respectively). In addition, Killer Cell Immunoglobulin-like Receptor (KIR) analysis revealed a deficit in the percentage of NK cells staining with an antibody recognizing KIR2DL1/S1 in the patient, but not in her healthy twin (7.0% vs 15.1% of NK cells, respectively), whereas no other differences in KIR receptor expression profiles were found for other KIR or in comparing the set of healthy twins. Analysis of frequencies of circulating Tregs revealed no difference between FL patient and her healthy twin: CD4+CD25+FOXP3+ cells represented 4.92% vs 5.78%, respectively of total CD4 cells and CD8+CD25+FOXP3+ cells represented 1.25% vs 1.37%, respectively of total CD8 cells. Analysis of T cell subsets revealed that Tregs in FL patient and in her twin were mainly of effector memory phenotype: CCR7-/CD45RA-/CD45RO+ (82.6% vs 74.4%, respectively) and central memory phenotype: CCR7+/CD45RA-/CD45RO+ (10.7 vs 14.3%, respectively). Conclusions NK cell studies of FL patient revealed increased numbers of activated CD69+ NK cells which correlated with increased degranulation response to tumor target cells and a deficit in the NK cell repertoire, as noted by the deficiency in NK cells expressing KIR2DL1/S1 in the patient compared to the healthy twin, while no differences in frequencies of circulating Tregs or Treg phenotypes were identified. Although the current results are based upon a single sampling, due to limited availability, the observed potentiation of NK cell activity in the patient with FL suggest a potentially important role of NK cells in tumor control during spontaneous partial remission. Follow-up studies of persisting remission, temporary flare-up or at disease progression will be of interest. Disclosures No relevant conflicts of interest to declare.

Optimal treatment of cutaneous B-cell lymphoma (CBCL) is yet to be established. We treated five patients, each with either extensive lesions, severe comorbidities or who refused treatment with radiation therapy, with rituximab given as a single agent for four weekly intravenous infusions of 375 mg/m(2). Maintenance therapy, if initiated, was given at 375 mg/m(2) once every 2-3 months. Objective clinical responses occurred in all five patients. Three patients have ongoing complete clinical remissions with a median follow-up of 17, 19 and 39 months post achievement of complete remission. One patient died at age 87 years from a non-related cause after 5.5 years of complete remission. One patient received local radiotherapy to a solitary cutaneous site of large-cell lymphoma that developed after 3 years in remission from the low-grade CBCL; no recurrences of either grade CBCL have yet occurred. Treatment was well tolerated. Rituximab is safe and effective in treating of CBCL, either primary CBCL or low-grade lymphomas with relapses limited to the skin. Rituximab appears to present an attractive alternative when radiation therapy is contraindicated or unwanted. Additional collaborative studies are needed to assess the role of rituximab in various clinicopathologic presentations of CBCL.

Fox Chase Cancer Center Partners (FCCCP) is a community hospital/academic partnership consisting of 25 hospitals in the Delaware Valley. Originally created in 1986, FCCCP promotes quality community cancer care through education, quality assurance, and access to clinical trial research. An important aspect of quality assurance is a yearly medical oncology audit that benchmarks quality indicators and guidelines and provides a roadmap for quality improvement initiatives in the community oncology clinical office setting. Each year, the FCCCP team and the Partner Medical Oncologists build disease site- and stage-specific indicators based on National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Concordance with multiple indicators is assessed on 20 charts from each community practice. A report for each FCCCP medical oncology practice summarizes documentation, screening recommendations, new drug use, and research trends in a particular disease site. Descriptive statistics reflect indicators met, number of new cases seen per year, number of disease site cases from tumor registry information, and clinical trial accrual total. Education and documentation tools are provided to physicians and oncology office nursing staff. The FCCCP Clinical Operations Team, consisting of medical oncologists and oncology-certified nurses, has conducted quality audits in medical oncology offices for 7 years using NCCN-derived indicators. Successful audits comprising gastric, colorectal, and breast cancer have been the focus of recent evaluations. For the 2005 stage II/III breast cancer evaluation, mean compliance per parameter was 88%, with 15 of 16 practices achieving mean compliance greater than 80%. A large-scale quality assurance audit in a community cancer partner network is feasible. Recent evaluation of localized breast cancer shows high compliance with guidelines and identifies areas for focused education. Partnership between academic and community oncologists produces a quality review process that is broadly applicable and adaptable to changing medical knowledge.

PURPOSE:Tumor-reactive T cells were measured in patients with chronic lymphocytic leukemia (CLL) because vaccines that increase the activity of these cells might lead to better disease control.EXPERIMENTAL DESIGN:Proliferation and ELISPOT assays (for T cells producing IFN-gamma after stimulation by CD40-activated CLL cells) were used to determine the prevalence of tumor-reactive T cells in 25 CLL patients at various stages of disease progression. The effects of vaccines, composed of autologous-oxidized tumor cells, on both the clinical course and tumor-reactive T-cell numbers were then determined in 2 patients.RESULTS:CLL-reactive T cells were found at frequencies of > or =10(-3) in 6 of 11 patients. Significant proliferation was found in 15 of 25 patients and correlated with clinical stage. The inability to measure CLL-reactive T cells in the remaining patients was not uniformly a result of generalized T-cell dysfunction or defective antigen presentation by CD40-activated CLL cells. CLL-reactive T-cell frequencies increased in response to vaccination with oxidized autologous tumor cells in a patient with preexisting CLL-reactive T cells but not in a patient where tumor-reactive T cells were undetectable in the ELISPOT assay.CONCLUSIONS:Tumor-reactive T cells exist in some CLL patients (mainly during earlier stages of disease) and may potentially mediate therapeutic responses if their numbers and activation states can be sufficiently increased by tumor vaccines.

In lymphomas an innate defect in the T-cell repertoire could account for the impaired tumour-specific immune response: alternatively, the tumour itself could exert an inhibitory effect on the immune system. To address this issue we analysed the T-cell responses against follicular lymphoma (FL) in identical twins as it can be postulated that their overall T-cell repertoire is identical. While differences between the T-cell response of the patient and the healthy twin would point to a tumour-induced T-cell unresponsiveness, impaired responses in both would point to a defective T-cell repertoire. We demonstrated an impaired tumour-specific proliferation (P = 0.035 and P = 0.013) and cytokine release (P = 0.004 and P = 0.0008) of both peripheral blood and tumour-derived T-cells, respectively, in the FL patient compared with the T-cell response of the healthy twin. Moreover, only syngeneic primed T cells were able to directly lyse unmodified FL cells of the patient. These data support previous findings in murine lymphomas and suggest that inhibitory mechanisms during tumour growth, rather than a defective T-cell repertoire, are responsible for the insufficient T-cell response in lymphoma.

Natural attenuation of ALVAC virus in mammals makes it an attractive vector for cancer vaccine therapy of immunocompromised hosts, such as patients with lymphoid malignancies. However, the transduction efficiency of ALVAC constructs in lymphoid tumors has not yet been characterized. We studied a wide spectrum of human T- and B-cell leukemia and lymphomas and found significant heterogeneity of the ALVAC-mediated gene product expression in these tumors. While ALVAC-B7.1, ALVAC-B7.2, or ALVAC-luciferase vectors effectively expressed recombinant genes in malignancies arising from T- or early B-cell precursors, negative or low expression of ALVAC recombinant genes occurred in tumors arising from mature B-cells. We showed that ALVAC-encoded B7.1 or B7.2 was continuously expressed on the infected, and subsequently irradiated, leukemia cells, and only cells with ALVAC-mediated expression of costimulatory molecules (but not unmodified leukemia cells or those infected with the ALVAC-parental vector) induced significant proliferation and IFN-γ production by alloreactive T-cells. These data provide the rationale for clinical studies using the ALVAC vector system for gene transfer into lymphoid tumors of T- and early B-cell origin to render them more immunogenic, while alternative strategies should be considered for immunotherapy of mature B-cell malignancies.