In vitro data suggest that the addition of bortezomib to chemotherapy can enhance the anti-myeloma activity achieved with either therapy alone. We hypothesized that combining bortezomib and DT-PACE in newly diagnosed MM can increase the CR rate and serve as a new mobilization regimen. The primary objective of the study is to determine the MTD of bortezomib (3 dose levels: 0.7, 1.0, 1.3 mg/m2 days 1, 4, and 8) in combination with thalidomide-based regimen (DT-PACE: dexamethasone 40 mg/day and thalidomide 200–400 mg/day orally x 4 days, Cisplatinum 10 mg/m2, Adriamycin 10 mg/m2, Cyclophosphamide 400 mg/m2 and Etoposide 40 mg/m2 all given by IVCI for 4 days). G-CSF 10 ug/kg/day was given from day 5 until stem cell collection or ANC > 2000, G-CSF was held on day 8 for Bortezomib dose. The secondary endpoint was to evaluate the effects of the mobilization regimen on the cellular composition of the graft and subsequent engraftment after high-dose chemotherapy. Five Pts have been enrolled on the study, median age 55 (range: 55–69), all had received 1–2 cycle of thalidomide based therapy, 2 had PD and 3 had PR. Three Pts were enrolled on dose level I; one Pt had grade III diarrhea and DVT with cycle one and tolerated cycle 2 well. One Pt had syncope with cycle 2. Two additional Pts were enrolled at dose level I with no grade III toxicity. After cycle 1, Pts underwent stem cell collections on day 13 (2 Pts had 1 collection and 3 had 2-day collection). Four Pts had a median of 21.7x 106 CD 34+/kg (range: 18.8–33.3) collected. One Pt continued thalidomide after day 4 through mobilization; he collected 4.3 x 106 CD 34+/kg. These collections compares favorably to those obtained from 14 Pts who collected stem cells after DT-PACE at our center in the past yr. This retrospective control group had a median of 14.5 days to collection (range: 11– 22d) with a median 17.8 x 106 CD 34+/kg (range: 9– 35). All 5 Pts responded to therapy; 3 had near CR and 2 PR after cycle 2. To date, 3 Pts received melphalan 200 mg/m2 followed by 4.3–5 x 106 CD 34+/kg and GCSF 5 mg/kg/day SC from day 5 until ANC > 1000 x 2 days. The first patient developed CMV antigenemia treated with ganciclovir. He received a boost of 5 x 106 CD 34/kg on day 21 and engrafted ANC > 1000 on day 25 and Plt > 20000 by day 49. The second patient reached ANC > 1000 on day 24 and plt > 20,000 by day 31. He developed autologous GVHD clinical grade II (skin and gut) upon engraftment, biopsy proven. He responded to steroids. The third patient whose cells were collected on thalidomide, engrafted ANC> 1000 by day 12 and Plt> 20000 by day 21, he has Plt < 30000 at day +35. The other 2 Pts await transplant. In comparison, control Pts mobilized with DT-PACE Pts (n=14) reached ANC > 1000 at a median of 12 days (range: 11-20) and plt > 20000 at 18 days (range: 13–25). Colony counts from DVT-PACE collections yielded a median CFU-C of 525 x 104/kg (range: 118–1000) compared to 540 (range: 153–1388) for DT-PACE. The effects of Bortezomib on the mobilized stem cells is unclear at this time, the delayed engraftment is concerning and will be better defined after additional Pts are treated on this protocol. Theoretically Bortezomib could affect stem cell adhesion molecules resulting in adequate stem cell collections and CFU-C in vitro that later affect stem cell homing and subsequent engraftment.

Bcl-2 acts as an important regulator of the mitochondrial pathway of apoptosis and promotes resistance of MM cells to chemotherapy. The Bcl-2 antisense oligonucleotide G3139 specifically targets Bcl-2 and may enhance the anti-tumor efficacy of Dex and Thal. In this trial G3139 was administered at 5 mg to the first 3 Pts and then 7 mg/kg/d by IVCI for 7d of 21d cycle. On day 4, Pts started Dex 40 mg daily for 4 d and Thal 100-400 mg as tolerated. After 3 cycles, responding Pts continued G3139 on a 5-week cycle with Dex 20 mg x 4d and Thal at the tolerated daily dose for up to 1 yr with an optional second yr for responding Pts. Thirty-three Pts treated to date had the following characteristics: median age 60 yrs (range: 28- 76), 22 males; 16 Pts had complex karyotypes; 14 Pts had B2M > 2.5 g/dl; LDH >1.5 normal in 7 Pts; Cr >1.5 mg/dl in 6 Pts; platelets <100,000/ul in 4 Pts. Pts had received a median of 3 prior regimens (range 2-4) including auto-SCT. Seventeen Pts had received prior Thal for a median duration of 6.5 mos. (range 2–8); 11 had no response or progressed on Thal. G3139/Thal/Dex regimen was well tolerated. The median number of cycles per Pt was 8 (range: 1–16). Toxicities included reversible increase in Cr from a median of 1.2 (0.6–2.5) at baseline to 1.5 (range: 0.9–2) at cycle 6. G3139 dose was decreased (3–5 mg/kg/d) for Cr elevations in teh majority of Pts. Thrombocytopenia <100K occurred between cycle 1 and 2 (P= 0.008), and was reversible. Other toxicities (>grade 2) included fatigue, neutropenia, fever, electrolyte disturbance, muscle cramps, rash, hypotension, constipation and infections. Only 3 Pts maintained 400 mg/d of Thal, most Pts required dose reduction to 50–200 mg/d due neuropathy. Thirty Pts were evaluable for response; 24 Pts (80%) had documented responses, including 2 CR, 4 near-CR (+ immunofixation) and 12 PR; 6 had minimal response and 6 Pts had PD. The median duration of response is 13 mos. The estimated PFS is 12 mos and the median OS is 17.4 mo. The upper limits of the 95% confidence interval for PFS and OS have not been reached. At a median follow up of 1 yr (range 1.5–16.6 mo), 7 Pts had died and 26 are alive, of them 16 Pts continue on the study. Responding Pts had an early and significant increase in polyclonal IgM from a median baseline of 35.5 mg/dl (range: 8–75) to 94 (45–211) after cycle 3 (P=0.005), suggesting activation of the innate immune system. CD138+ cells were isolated from BM aspirates pre-treatment, and on d 4 or 7, and 28. Western blot analysis of Bcl-2 protein demonstrated demonstrated a decrease in Bcl-2 levels after normalization for protein loading by densitometry in 3 of 7 Pts with sufficient cells for analysis. The change of Bcl-2 protein levels did not correlate with response. Real time quantitative RT-PCR analysis was subsequently used to evaluate changes in Bcl-2 gene expression. Of 9 Pts evaluated, 6 demonstrated a significant decrease in Bcl-2 mRNA expression when normalized against GAPDH; 5 of them had a clinical response. In conclusion, G3139, Dex and Thal regimen is well tolerated in relapsed MM Pts. G3139 was associated with significant decrease in Bcl-2 gene expression in some Pts. G3139 appears to over-come resistance to Dex/Thal with impressive clinical responses in relapsed/refractory MM patients.

Relapse remains a major cause of treatment failure after autotransplantation (auto-PBSCT) for Hodgkin's disease (HD). The administration of non-crossresistant therapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after auto-PBSCT in 37 patients with relapsed or refractory HD. Patients received high-dose gemcitabine-BCNU-melphalan and auto-PBSCT followed by involved-field radiation and up to four cycles of the DCEP-G regimen, which consisted of dexamethasone, cyclophosphamide, etoposide, cisplatin, gemcitabine given at 3 and 9 months post transplant alternating with a second regimen (DPP) of dexamethasone, cisplatin, paclitaxel at 6 and 12 months post transplant. The probabilities of event-free survival (EFS) and overall survival (OS) at 2.5 years were 59% (95% CI=42-76%) and 86% (95% CI=71-99%), respectively. In all, 17 patients received 54 courses of CC and 15 were surviving event free (2.5 years, EFS=87%). There were no treatment-related deaths during or after the CC phase. Post-transplant CC is feasible and well tolerated. The impact of this approach on EFS should be evaluated in a larger, randomized study.

Summary: Four patients with chronic myelogenous leukemia (CML) that was refractory to interferon alpha (two patients) or imatinib mesylate (two patients), and who lacked donors for allogeneic stem cell transplantation, received autotransplants followed by infusions of ex vivo costimulated autologous T cells. At day +30 (about 14 days after T-cell infusion), the mean CD4+ cell count was 481 cells/ μ l (range 270–834) and the mean CD8+ count was 516 cells/ μ l (range 173–1261). One patient had a relative lymphocytosis at 3.5 months after T-cell infusion, with CD4 and CD8 levels of 750 and 1985 cells/ μ l, respectively. All the four patients had complete cytogenetic remissions early after transplantation, three of whom also became PCR negative for the bcr/abl fusion mRNA. One patient, who had experienced progressive CML while on interferon alpha therapy, became PCR− post transplant, and remained in a molecular CR at 3.0 years of follow-up. All the four patients survived at 6, 9, 40, and 44 months post transplant; the patient who remained PCR+ had a cytogenetic and hematologic relapse of CML, but entered a molecular remission on imatinib. Autotransplantation followed by costimulated autologous T cells is feasible for patients with chronic phase CML, who lack allogeneic donors and can be associated with molecular remissions.