Ansell, Steven M.

Abstract Background: mTOR inhibition has produced responses in mantle cell lymphoma as well as other non-Hodgkin lymphomas. This phase II study tested the oral mTOR inhibitor everolimus (RAD001, Novartis Pharmaceuticals) in simultaneous two-stage phase II lymphoma studies, including one arm involving Hodgkin lymphoma. The goals were to learn the toxicity profile and to assess the anti-tumor response. A total of 17 patients with Hodgkin lymphoma were enrolled in the uncommon arm at completion of enrollment. Methods: Patients (pts) received 10 mg PO daily for each 28 day cycle (up to 12, with a possible extension in responders) and restaged after 2, 6, and 12 cycles. The primary endpoint is the confirmed response rate, including CR, CRu or PR. Results: The median age of the 17 pts with Hodgkin lymphoma was 37 yrs (range: 27–68), with a median of 6 (range, 4–14) prior therapies. Fourteen pts (82.4%) had a prior stem cell transplant (SCT). Pts completed a median of 6 (range, 1–13) cycles of therapy. Fifteen of 17 patients were evaluable for response as of this analysis. The overall response rate was 47% (7/15), all partial responses. Ten patients are continuing on study while 6 have gone off due to disease progression and 1 due to other reasons. Common grade 3 adverse events (AEs) include thrombocytopenia (5 pts), anemia (5 pts) and alkaline phosphatase elevation (1 pts). 1 patient was reported to have grade 4 neutropenia. Conclusions: Oral everolimus has promising activity with acceptable toxicity in Hodgkin lymphoma. These results provide the rationale for additional studies with this novel class of agents and to integrate mTOR inhibitors into salvage treatment regimens for Hodgkin lymphoma.

Abstract Waldenström macroglobulinemia (WM) is a B-cell malignancy that is characterized by the production of a monoclonal IgM protein, a lymphoplasmacytic infiltrate in the bone marrow, and associated symptoms including anemia, lymphadenopathy and hyperviscosity. The aberrant production of a monoclonal IgM in the serum is a major factor causing significant morbidity in patients with this disease, yet little is known about the mechanisms that regulate monoclonal protein synthesis. While recent gene array studies and serum analysis have shown that IL-6 is elevated in WM patients suggesting an important role for this cytokine in this disease, the precise role played by IL-6 in WM is unknown. Using a multiplex ELISA approach to screen sera from WM patients, we confirmed that IL-6 was significantly elevated (p<0.0019) in patients (n=20) compared to controls (n=20). Serum levels of IL-6 in WM patients correlated with elevated levels of β2-microglobulin (p<0.0019). Additionally, we also found that serum levels of CCL5 (Rantes) were significantly elevated in WM patients (p<0.0001). CCL5 has been shown to regulate IL-6 secretion, and we therefore wanted to determine if CCL5 influenced IL-6 expression in WM and what the subsequent consequence of IL-6 stimulation was on WM cells. To define the source of IL-6 in the tumor microenvironment, we used stromal cells from the bone marrow of healthy donors, malignant cells from patients with WM, and the BCWM.1 WM cell line, and tested their ability to secrete IL-6 by ELISA. All cell types secreted IL-6, with stromal cells secreting the most. We then tested the ability of CCL5 to induce IL-6 secretion by WM and stromal cells. CCL5 significantly increased IL-6 secretion by stromal cells (p<0.03) and also increased IL-6 secretion by fresh CD19+ CD138+ cells from WM patients (p<0.02). Using fresh patient WM cells and the BCWM.1 WM cell line as a model, we then determined the effect of IL-6 on growth of WM cells. We found that IL-6 had a modest effect (mean=20% increase, range=5–41%) on cell proliferation (p<0.0039) but had no effect on cell viability. In contrast, when we addressed the role of IL-6 on IgM secretion, we found that IL-6 increased IgM secretion by BCWM.1 cells in a dose-dependent manner. The IL-6 mediated increase in IgM secretion was abolished in the presence of neutralizing antibodies to IL-6. When we analyzed the downstream signaling events activated by IL-6 in WM cells we found that stimulation of BCWM.1 cells, which express the IL-6R, resulted in phosphorylation of Stat1, Stat3 and Erk1/2, but not Akt. Using a mitogen activated protein kinase (MAPK) inhibitor, we could inhibit the IL-6-mediated phosphorylation of Erk1/2. Similarly, using a JAK1 Inhibitor, we could inhibit IL-6 mediated signaling through Stat1 and Stat3. In summary, we have clearly shown that IL-6 significantly upregulates IgM secretion by WM cells and increases their proliferation. We have also demonstrated the ability of both the malignant cells and the stromal cells to secrete IL-6, and that this secretion is regulated in part by CCL5. We have found that WM cells express IL-6R, and that IL-6 induced signaling is through both the MAPK and Jak/Stat pathways. Therapies targeting IL-6 secretion or the IL-6 signaling pathways may therefore provide clinical benefit to patients with WM; not just by inhibiting the malignant cells but by down regulating the production of the monoclonal protein.

Background:Predicting early clinical failure in patients with untreated follicular lymphoma (FL) is important but difficult. Lymphoma involvement of extranodal (EN) sites is better detected by FDG‐PET/CT than CT alone, but PET parameters are not part of the usual predictive indices.Aims:We aimed to determine the incidence and patterns of EN and spleen disease, and learn if they were useful in predicting early clinical failure.Methods:PET/CT images from 613 cases of newly diagnosed FL between 2003 – 2016 were retrospectively reviewed for EN and spleen involvement. The location, number, and pattern of EN sites, as well as splenic involvement, were recorded. Associations with outcomes were assessed using event‐free survival (EFS), overall survival (OS), and early clinical failure at 24 months (EFS24).Results:49% (301/613) of patients had PET/CT‐detected EN involvement, and 28% (171/613) had spleen involvement. Presence of ≥2 EN sites, spleen, bone or soft tissue involvement all predicted failure to achieve EFS24. These factors, as well as pattern of bone involvement by imaging, were predictors of EFS on univariate analysis; presence of ≥2 EN sites and bone involvement pattern were also predictive of OS. In a multivariate analysis with FLIPI‐2 factors, spleen involvement, pattern of bone involvement, and soft tissue involvement independently predicted a lower EFS (Table 1). When the multivariate analysis was performed using PRIMA‐PI factors (marrow and B2 M), the presence of ≥2 EN sites was an adverse independent prognostic factor for OS (HR 2.28; 95% CI 1.01–5.18; p = 0.05).Table 1: Extranodal and spleen involvement by PET/CT as predictors of event‐free survival Summary/Conclusion:Baseline PET/CT identifies EN and spleen sites of disease that can predict early clinical failure in FL. These results, when combined with other factors, may better identify high‐risk patients and guide appropriate therapy.imageimage