Zent, Clive S.

Abstract The standard of care for CLL is to treat only patients with obvious clinical progression because earlier intervention is not of proven benefit. The discovery of more accurate prognostic markers for CLL could change that paradigm. The predictors of more aggressive disease include 17p13 deletion (17p13−), 11q22-3 deletion (11q22−), unmutated (UM) immunoglobulin heavy-chain variable region (IgVH), and expression of ZAP-70 and CD38. In addition, monoclonal antibody (MoAb) therapies provide effective treatment with less toxicity than chemotherapy and are likely to be most efficacious in early stage CLL. The combination of alemtuzumab (ALEM) and rituximab (RIT) is of interest because of non-overlapping mechanisms of action. ALEM is also effective therapy for patients with defects in the p53 apoptotic pathway that are more resistance to purine analogue therapy. We tested the hypothesis that MoAb therapy with ALEM and RIT will eliminate/greatly decrease the high risk clone characterized by 17p13−, 11q22−, or UM IgVH plus either ZAP70+ or CD38+, in early stage CLL. Methods This trial will enroll a maximum of 30 patients and be considered promising if ≥ 19 patients respond. All patients with previously untreated CLL (Rai stage 0 −II) not meeting NCI-WG 1996 treatment criteria and with a high risk CLL clone were evaluated for enrollment. Treatment duration was 30 days (subcutaneous ALEM dose escalation, 3 mg - 10 mg - 30 mg on days 1–3) then 30 mg Monday, Wednesday and Friday for 4 weeks. RIT (375 mg/m2/dose IV x 4) was administered weekly staring on day 8. All patients received PCP and herpes virus prophylaxis and had CMV viral DNA testing for 7 months. Response was evaluated using NCI-WG 1996 criteria and minimal residual disease (MRD) was measured in peripheral blood using sensitive flow cytometry (1:104) for CD19+/CD5+/CD79b− lymphocytes. Results Since January 2005, 17 patients have been enrolled and the interim analyses are for the first 11 patients accrued. Median age was 62 years (29 – 75) with 6 males and 5 females. The qualifying high risk features were 17p13− (n = 4), 11q22− (n = 3), and UM IgVH + CD38+ +/− ZAP-70+ (n = 4). Median time from diagnosis to treatment was 11 months (2–72). Clinical stage (Rai) was 0 in 3 patients, I in 5 patients and II in 3 patients. Median absolute lymphocyte count was 25.6 x 109/L (15.9 – 81.8), Hgb 14.4 g/dL (12 – 15.8), and platelet count 171 x 109/L (125 – 312). Two patients had serious adverse reactions requiring intervention (CMV reactivation responsive to treatment; febrile drug reaction to sulfamethoxazole/trimethoprim). Grade 3–4 adverse reactions not requiring interventions were leukopenia (n = 4), neutropenia (n = 2), anemia (n = 1), elevated ALT (n = 1), and skin reaction to ALEM (n =1). There were no “first dose” reactions. All patients responded to therapy with 5 CR (4 of these MRD negative), 3 nodular PR, and 3 PR. Median duration of response has not yet been reached at median follow up of 11.7 months (6.5 – 14.9). Patients with a MRD negative CR had recurrence of detectable MRD at 120 – 210 days after completing therapy but all remain in CR. One patient died off study of complications of a myeloablative allogeneic transplant for progressive CLL. Discussion ALEM and RIT is effective and tolerable therapy for early stage high risk CLL. All patients responded with 36% achieving a MRD negative CR but serial MRD assays showed that the CLL clone was not deleted. This promising, treatment requires further improvement.

Abstract Background: CLL is a disease of the elderly and at least half of the patients requiring therapy are over age 70. While chemoimmunotherapy (CIT) has dramatically improved response rates in patients with CLL, some CIT regimens are not well tolerated by elderly patients. The MD Anderson group has reported that the fludarabine, cyclophosphamide, rituximab (FCR) regimen is not well tolerated in individuals ≥age 70 (Ferrajoli Leuk Lymph 46:S86). The German CLL Study Group has postulated that physiologic health is more important than chronologic age and have conducted a trial of FCR that permits enrollment of patients ≥age 70 provided they have a creatinine clearance (CrCl) ≥70 and good performance status (PS). While this approach expands the number of individuals who can receive CIT, it still excludes large percentages of CLL patients in need of treatment. Here, we examine how age, CrCl, and PS relate to the efficacy and tolerability of the pentostatin, cyclophosphamide, and rituximab (PCR) regimen. Methods: We treated 64 previously untreated CLL patients meeting NCI 96 criteria for treatment with pentostatin (2mg/m2), cyclophosphamide (600 mg/m2) and rituximab (375mg/m2) (Kay ASH 2006). All medications were administered on day 1 of every 3 week cycle with the intent of administering 6 cycles. We measured ECOG PS at study entry and used age, weight, and baseline creatinine to calculate the CrCl of all patients at study entry using the Cockroft-Gault equation. Results: Eighteen of 64 patients (28%) were ≥age 70. Although individuals ≥age 70 were more likely to have a dose delay of >1 week at some point during the trial (7% vs. 28%; p=0.03), there was no difference in the average number of cycles administered, the number of patients requiring dose reductions, or the number of patients with grade 3/4 hematologic toxicity, infectious complications, or other non-hematologic toxicity. No difference in OR (93% vs 83%; p=0.34) or CR (41% vs. 39%; p=0.86) was observed between patients <age 70 compared to those ≥70. We next evaluated whether CrCl related to the efficacy and tolerability of PCR. 25 patients (39%) had a CrCl<70, including 15 (23%) with a CrCl<60 and 5 (8%) with CrCl<50. Although individuals with CrCl<70 were more likely to have a dose reduction (5% vs. 24%; p=0.05), there was no difference in the average number of cycles administered, the number of patients requiring a dose delay, or the number of patients with grade 3/4 hematologic toxicity, infectious complications, or other non-hematologic toxicity. No difference in OR (89% vs 92%; p=1.0) or CR (45% vs. 36%; p=0.60) was observed between patients with CrCl≥70 and those with CrCl<70. We next evaluated how PS related to the efficacy and tolerability. 34 patients (53%) were PS 0 and 30 (47%) were PS≥1. This analysis suggested PCR was well tolerated among those with PS≥1. Again no difference in the OR or CR was observed between patients with PS 0 and those with PS≥1. Conclusions: In this phase II clinical trial, the PCR regimen was well tolerated by patients ≥age70, those with higher PS, and the 25 individuals with CrCl≤70 (range 34–67). The efficacy of PCR was also not significantly affected by age, renal function, or performance status. These findings suggest the PCR regimen may be superior to the FCR regimen for elderly patients and those with decreased renal function.

Abstract Background: The prognosis of patients with early Rai and Binet stage CLL is variable. Recently developed prognostic tests (mutation status, ZAP-70, chromosome evaluation by FISH) require significant technologic expertise and are not available worldwide to most patients with CLL. Smudge cells are ruptured CLL cells appearing on a blood smear. Using a proteomic approach, we recently discovered that the cytoskeletal protein vimentin is expressed at higher levels in CLL cells with unmutated IgVH and that vimentin expression is a marker of poor prognosis in early stage CLL (Blood, 2005;106:707). Hypothesis: Since vimentin plays an important role in the cytoskeleton and lymphocyte rigidity, we hypothesized that smudge cell formation is inversely correlated with vimentin expression and that the percentage of smudge cells may predict prognosis in CLL. Methods: We blindly reviewed the blood smears archived at the time of diagnosis of patients with untreated, early stage CLL. A total of 200 lymphocytes and smudge cells were counted per slide and results reported as percentage of total lymphocytes (intact and smudged). The percentage of smudge cells was correlated with vimentin expression measured by flow cytometry, IgVH mutation status, time to treatment (TTT), and survival. Results: Blood smears of 75 patients were reviewed. The median percentage of smudge cells was 27% (range, 4–72%). The percentage of smudge cells did not correlate with lymphocytosis (r=0.04, p=0.73) and did not change overtime for serial evaluations for individual patients (p=0.61). The percentage of smudge cells appeared to correlate inversely with vimentin expression (r = − 0.627; p = 0.0017). The percentage of smudge cells was higher in patients with mutated IgVH than in patients with unmutated IgVH (median 31% vs. median 13%, p=0.02). The percentage of smudge cells as a continuous variable correlated with both a prolonged TTT (p=0.0023) and overall survival (p=0.04). Patients with less than 30% smudge cells had a median TTT of 72.7 months. The median TTT in patients with ≥30% smudge cells was not reached (p=0.0011), Figure 1. Conclusion: A lower percentage of smudge cells is associated with unmutated IgVH status and with worse clinical outcome in early stage CLL. The percentage of smudge cells does not vary based on the magnitude of the lymphocytosis, but is patient specific and remains constant over time. Evaluation of the percentage of smudge cells on blood smears could be a universally available prognostic test for patients with early stage CLL. Figure Figure

Abstract Chronic Lymphocytic Leukemia (CLL) is primarily characterized by the presence of leukemic B lymphocytes resistant to the process of apoptosis. Causes for this resistance include aberrant expression of multiple anti-apoptotic proteins, perhaps including Tcl-1 (1). Tcl-1 is expressed during normal development of both B and T cells and activates Akt to provide a survival signal through phosphorylation and inactivation of apoptotic pathway components. Overexpression of Tcl-1 in the B cells of transgenic mice results in a B-cell leukemia phenotype typical of human CLL, suggesting a primary role for Tcl-1 in CLL tumorigenesis. A recent report showed that Tcl-1 protein expression in CLL cells correlated with other biological parameters, but no data were available as to its clinical relevance (2). We therefore examined Tcl-1 expression in relation to clinical outcome using 51 peripheral blood mononuclear cell samples from a Phase II clinical trial testing the combination of pentostatin, cyclophosphamide, and rituximab in previously untreated CLL patients (Kay et al., ASH 2006). Tcl-1 protein expression was measured by immunoblot using GAPDH as a normalization control across lanes and lysate from a single Tcl-1 transgenic mouse spleen as a normalization control across immunoblots. All samples were run at least in duplicate and digital quantitation was performed using a ChemiDoc instrument (BioRad). Tcl-1 expression in patient cells was calculated in comparison to Tcl-1 expression in the mouse lysate, arbitrarily set to 1.0. Data were analyzed as a continuous measure as well as by specific cutoffs. Higher Tcl-1 expression was associated with failure to achieve a minimal residual disease-negative state after treatment. Specifically, Tcl-1 expression (measured as a continuous variable) was associated with residual disease measured by post-treatment CD5+/CD19+ cell percentages (continuous variable as well as dichotomized by cutpoint of 1.0% for CD5+/CD19+; p=0.03 for both comparisons). For the dichotomized Tcl-1 expression with the cutpoint of 0.275 (second tertile), this variable was marginally significantly associated with whether or not post-treatment CD5+/CD19+ was less than 1.0%. Using this same cutoff, there was also a suggestion that patients with reduced Tcl-1 were more likely to achieve a complete response. Finally, progression-free survival was shorter in patients with increased Tcl-1 expression, although these data did not reach statistical significance in this sample set. Tcl-1 < 0.275 Tcl-1≥ 0.275 p value CD5/CD19≥ 1% 15 10 0.046 CD5/CD19 < 1% 16 2 CR 17 3 0.064 No CR 18 13 Median PFS (mos.) 36.5 17.1 0.137 Statistically significant associations with other parameters including Rai stage, IgVH mutation status, ZAP-70 expression, CD38 expression, and interphase cytogenetics categories were not detected in this sample set. These data further support the clinical relevance of the Tcl-1 mouse model to human CLL, and provide preliminary evidence that Tcl-1 protein expression correlates with clinical outcome of CLL patients treated with chemoimmunotherapy. If validated in larger studies, Tcl-1 expression may serve as a novel prognostic factor.

Abstract BACKGROUND: B-Chronic Lymphocytic Leukemia (CLL) is still uncurable but very powerful new tools are available with the use of chemoimmunotherapy (CIT). Purine nucleoside-based regimens that incorporate rituximab have generated very high levels of overall responses (OR) with significant percentage of those complete responses (CR) in previously untreated CLL. Here we report and update our experience with a phase 2 pentostatin-based CIT regimen for previously untreated CLL as conducted at 2 medical centers. We also studied the association of outcome based on risk stratification parameters and achievement of minimal residual disease. METHODS: Building on prior work of pentostatin in CLL by us (Kay ASH, 2004) and others, we initiated a trial of combined pentostatin (P)(2 mg/m2), cyclophosphamide (C)(600 mg/m2) and rituximab (R)(375 mg/m2) for symptomatic, previously untreated patients (n=65). This PCR regimen is given on a 21-day, 6-cycle schedule. However, the initial cycle of treatment uses thrice weekly rituximab as described by us earlier. In brief, this was rituximab at 100 mg/m2 on day 1, 375 mg/m2 on days 3 and 5 of the first week only. Prophylactic Sulfamethoxazole/Trimethoprim and Acyclovir were given to all patients for 1 year starting on the first cycle of therapy with PCR. All patients were risk stratified using CD38, ZAP-70, immunoglobulin heavy chain variable region gene (IgVH) and FISH panel assessments at entry. RESULTS: These patients were characterized as mostly in high-risk categories. Of 64 evaluable patients, 34 (53%) were high Rai risk (stage 3–4), 71% were non mutated for the IgVH gene, 34% were CD38+ and 34% were ZAP-70+. Thirty patients (52%) had one FISH anomaly, and 21 (36%) had complex FISH defects. Thirty-eight patients (58%) had grade 3+ hematologic toxicity but minimal transfusion needs, and no major infections. NCI Working Group Criteria Responses occurred in 58 (91%) with 26 (41%) complete responses (CR), 14 (22%) nodular partial responses (nodular PR), and 18 (28%) partial responses (PR) patients. Outcome for all 64 patients demonstrates a median progression-free survival of 32.6 months. Importantly, no high risk factor (i.e., age, FISH, IgVH status, CD38+, ZAP-70+) except for del (17p) defect (n=3) precluded attaining a CR or NPR. In contrast, we found this regimen was equally effective in young vs. elderly (>70 yrs) patients and in del(11)(q22.3) vs. other favorable prognostic FISH factors. Examination of outcome among CR and nodular PR patients for PFS by flow cytometry status (negative vs. positive, i.e., ≤ 1 % CD5+/CD19+ vs. ≥ 1 % CD5+/CD19+) demonstrated improvement in progression free survival for patients who attained flow cytometry negativity (p = 0.009). Conclusion: This novel regimen of pentostatin, cyclophosphamide and rituximab for previously untreated CLL demonstrated significant clinical activity despite poor risk-based prognoses with minimal toxicity in terms of bone marrow suppression and/or infections. The additional feature of this approach is the ability to have durable responses for all age groups and even CLL patients with a del(11)(q22.3).

Abstract Abstract 2902 Background: Although chronic lymphocytic leukemia (CLL) is a low grade B-cell malignancy, 2–8% of patients (pts) are reported to undergo transformation to diffuse large B-cell lymphoma (DLBCL; Richter's syndrome [RS]). Whether the risk of transformation is related to the underlying biology of CLL or is a consequence of treatment for CLL is uncertain. Also, the role of prognostic markers such as immunoglobulin heavy chain (IGHV) gene mutation status, ZAP-70 and CD38 expression, and genetic abnormalities detected by fluorescence in situ hybridization (FISH) in predicting the development of RS is not well defined. The available data on stem cell transplant (SCT) in pts with RS is based on retrospective case series of selected RS pts and is of uncertain relevance to the majority of CLL pts experiencing RS. Therefore, we conducted a cohort study of newly diagnosed CLL pts to explore the incidence and natural history of RS. Methods: The Mayo Clinic CLL database includes all consenting pts with a pathologic diagnosis of CLL. Information on date of diagnosis, treatment history, and disease-related complications is abstracted from clinical records on all pts and then maintained prospectively. We used this database to identify newly diagnosed pts with CLL from January 2000 through July 2011, who were seen at our institution within 12 months of diagnosis. Pts with biopsy-confirmed RS were included in this analysis. For pts referred from an outside institution, pathology review at Mayo Clinic was mandatory to be included in this study. The Mayo Clinic Institutional Review Board approved the study. Results: Between January 2000 and July 2011, 1641 pts with newly diagnosed CLL were seen at Mayo Clinic within 12 months of diagnosis, and this cohort had a median follow-up of 4.0 yrs (range, 0–12.3 yrs). Of these pts, 37 (2.3%) were diagnosed with RS. The median time to development of RS after a diagnosis of CLL was 1.8 yrs (range, 0–11.7 yrs). The incidence of RS at 2 and 5 yrs post CLL diagnosis were 1.3% and 2.1% respectively (Figure). Pts who developed RS had more advanced (Rai III/IV) stage disease (22% vs. 6%; p<0.001) and higher beta 2-microglobulin levels (median 3.1 mg/dL vs. 2.3 mg/dL; p=0.003) at diagnosis of their CLL compared to pts without RS. Pts who developed RS were also more likely to be positive for ZAP-70 (58% vs. 33%; p=0.03), CD49d (77% vs. 31%; p=0.0004), and CD38 (57% vs. 29%; p=0.001), have unmutated IGHV (76% vs. 44%; p=0.003) and have either del(11q22.3) or del(17p13) on FISH analysis (46% vs. 13%; p<0.0001). RS transformation occurred prior to treatment of CLL in 17 (46%) pts and after treatment of CLL in 20 pts (54%). Treatment for CLL was associated with an increased risk of RS (92% vs 34%; p<0.0001). The odds ratio (OR) of RS was increased for pts who received purine nucleoside analogues (OR=3.0; 95%CI=[1.6, 5.9]; p=0.001), alkylating agents (OR=2.5; 95% CI=[1.3, 4.9]; p=0.004), or both (OR=3.3; 95% CI=[1.7, 6.4]; p=0.0003) for treatment of their CLL. Median overall survival after development of RS was 2.1 yrs. Most pts (29/37, 78%) received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) therapy. Two (5%) pts underwent an autologous SCT and 5 (14%) underwent an allogeneic SCT. Additionally, 1 (3%) patient received an autologous SCT followed by an allogeneic SCT. By the end of the study period, 17 (46%) pts with RS had died. Conclusion: The overall rate of biopsy-proven RS in this large cohort of pts with newly diagnosed CLL was 2.3% (5 year incidence: 2.1%). Clinical characteristics (Rai stage III/IV) and biologic characteristics of the CLL B-cell (positive expression of ZAP-70, CD38 and CD49d; unmutated IGHV; and either del(11q22.3) or del(17p13) on FISH) at the time of diagnosis were associated with future risk of RS. Exposure to purine nucleoside analogues and/or alkylating agents for treatment of CLL was also associated with increased risk of RS. Disclosures: Zent: GlaxoSmithKline: Research Funding; Novartis: Research Funding; Genentech: Research Funding; Genzyme: Research Funding; Biothera: Research Funding. Shanafelt:Genentech: Research Funding; Glaxo-Smith-Kline: Research Funding; Cephalon: Research Funding; Hospira: Research Funding; Celgene: Research Funding; Polyphenon E International: Research Funding.

Abstract Abstract 1792 High risk disease can be identified in patients with early stage chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) using biological prognostic markers. We have shown that early therapy of high risk CLL patients with alemtuzumab (ALM) and rituximab (RTX) is effective and could possibly delay first standard treatment (Cancer 2008;113:2110-8). Efficacy of unconjugated monoclonal antibody (mAb) therapy in these patients could be improved by enhancing mAb mediated cellular cytotoxicity. Preclinical studies show that yeast cell wall derived beta glucan, which increases complement receptor 3 (CR3) binding to the complement fragment iC3b on target cells, could increase mAb mediated cellular cytotoxicity. Both ALM and RTX activate complement resulting in deposition of iC3b on the cell membrane. In CLL cells that are not lysed by complement activation, these iC3b molecules are targets for the effector cells mediating cellular cytotoxicity. We hypothesized that PGG beta glucan (Imprime PPG®, Biothera, Eagan MN) an intravenous formulation of a 1,3/1,6 glucose polymer prepared from a strain of Saccharomyces cerevisiae, would improve the efficacy of therapy with ALM and RTX in patients with CLL by increasing CR3 binding to iC3b and thus enhancing macrophage, neutrophil, and NK cell mediated cytotoxicity. We report the results of a Phase I study of the combination of ALM, RTX and PPG beta glucan in patients with CLL. Methods: The primary aim of this IRB approved study (NCT01269385) was to determine the maximum tolerated dose (MTD) of PGG beta glucan that could be safely combined with ALM and RTX. The MTD was defined as the PGG beta glucan dose level below that which induced dose limiting toxicity in at least one third of patients, or the highest dose level tested if all levels were tolerated. Eligibility for the trial required a diagnosis of CLL by standard (IWCLL-NCI 2008) criteria, no prior treatment for CLL, high risk CLL based on molecular markers, absence of standard indications for initiation of therapy for CLL, and adequate performance status and organ function. High risk CLL was defined as at least one of the following: 17p13-; 11q22-; either unmutated (<2%) IGHV or use of VH3–21 as well as CD38+ and/or ZAP70+. Patients received standard premedication for mAb, antimicrobial and allopurinol prophylaxis and weekly PCR testing for CMV reactivation with treatment of viremia. The duration of treatment was 33 days. PGG beta glucan was administered IV on days 1, 5, 10, 17, 24, and 31 and the first dose was premedicated with hydrocortisone 100mg IV, oral acetaminophen 1000 mg and diphenhydramine 50 mg. The starting dose level of PGG beta glucan was 1 mg/kg, 2nd dose level was 2 mg/kg and the 3rd dose level 4 mg/kg. Subcutaneous ALM therapy started on day 3 with daily dose escalation (3 – 10 – 30 mg) and then 30 mg Mon-Wed-Friday for 4 weeks. Weekly RTX started on day 10 at 375 mg/m2 IV × 4 doses. Results: Thirteen patients were enrolled from February 2011 to April 2012. The 11 evaluable patients had a median age of 61 years (range 47 – 77), 73% were male, 3 had early stage disease (Rai 0) and 8 had intermediate stage disease (Rai I n = 7, Rai II n = 1). High-risk parameters were 17p- in 4 patients, 11q22- in 3 patients, and unmutated IGHV and expression of ZAP70 and/or CD38 in 4 patients. There were no dose limiting toxicities. One patient had grade 4 febrile neutropenia, with no grade 3–4 anemias or thrombocytopenias, and there were no grade 3–4 non-hematological toxicities. All patients responded to therapy with 7 CR, 1 CCR, 1 nPR, and 2 PR (IWCLL-NCI 2008 criteria). Median follow up was 6.9 months (2.3 – 13.2) and one patient progressed at 9.7 months. No patients have required treatment for progressive disease and there have been no patient deaths. Two patients were not evaluable: One developed neutropenia and therapy was not held per protocol, and the other developed a grade 2 skin reaction to ALM and treatment was stopped. Discussion: The combination of PGG beta glucan with ALM and RTX is well tolerated at a PGG beta glucan dose of 4 mg/kg. All patients responded to therapy with 64% achieving a CR. These data support continuation of this study in a phase II component. Acknowledgment: This study was funded by the University of Iowa/Mayo Clinic Lymphoma SPORE (CA097274) and Biothera. Disclosures: Zent: Biothera: Research Funding; Genzyme: Research Funding; Genentech: Research Funding; Novartis: Research Funding; GlaxoSmithKline: Research Funding. Off Label Use: Phase I study using PGG beta glucan in CLL.

Abstract Results from the Phase I portion of this study in high risk chronic lymphocytic leukemia (CLL) patients (pts) (NCT01269385) showed that the combination of Imprime PGG (IPGG) at doses up to 4 mg/kg, with alemtuzumab (ALM) and rituximab (RTX), was well tolerated and associated with a 73% complete response (CR) rate (Blood 120: Abstr 1792, 2013). IPGG is a yeast-derived beta 1,3/1,6 glucan that engages innate immune cells, enhancing anti-tumor activity in combination with complement activating monoclonal antibodies (mAb) via a mechanism involving complement receptor 3 (J Immunol 177:1661, 2006). Endogenous anti-beta glucan antibodies (ABA) are required for IPGG binding to complement receptors and modulation of innate immune cell function. In pts with stage IV non-small cell lung cancer (NSCLC), correlation between serum ABA concentrations and response to an IPGG-containing frontline regimen has been observed (J Clin Oncol 32: 15S; Abstr 3045, 2014). Here we report clinical and translational results at the end of the Phase II portion of this CLL study. Methods: The primary endpoint of the Phase II study was the proportion of pts experiencing CR 3 months after completing 5 weeks of treatment with IPGG 4 mg/kg, ALM and RTX. Eligible pts (n=14) had a diagnosis of CLL by standard criteria (IWCLL-NCI 2008), no prior treatment for CLL, high risk CLL based on molecular markers (17p13-; 11q22-; unmutated [<2%] IGHV and/or use of VH3-21 AND CD38+ [³30%] and/or ZAP70+ [³20%]), no standard indication for initiation of CLL therapy, and adequate performance status and organ function. Planned enrollment was up to 39 pts but the study was terminated early due to slow accrual. Translational studies evaluated baseline serum ABA levels and in vitro binding of IPGG to immune cell subsets in whole blood. Results: The median age was 63.5 (range 47-77); 71% were male; and 6 (43%), 5 (36%) and 3 (21%) pts had Rai Stage 0, 1 and 2, respectively. CLL high-risk parameters were 17p13- in 3 (21%), 11q22- in 5 (36%), and unmutated IGHV or use of VH3-21 together with either expression of ZAP70 and/or CD38 in 6 (43%) pts. Grade 3 AEs were diarrhea (n=3) and increased transaminase levels, dehydration, gastritis, hypertension, hyponatremia, and hypertension (each n=1). Grade 4 AEs were neutropenia (n=2) and febrile neutropenia (n=1). Thirteen (93%) patients responded to therapy, with 7 CR, 2 CR with incomplete marrow recovery, 1 nodular PR and 3 PR (IWCLL-NCI 2008 criteria). Median follow-up was 12.7 mo (range 6.7 - 28.0). The overall median duration of response cannot be determined, as only 5/13 responders have progressed (median of 5.6 mo; range: 2.9 - 8.5) and the other 8 remain progression-free after a median of 8.0 mo (range 5.6 - 21.0). Four progressing pts were retreated after a median of 14.2 mo (range 12.4 - 20.5). There were no deaths during or after treatment. Translational studies demonstrated a correlation between ABA concentrations and binding of IPGG to neutrophils, monocytes and B-cells. However, there was no correlation between ABA concentrations and response to treatment. Potential functional implications of binding of IPGG to leukemic B cells, including direct and indirect enhancement of the antibody-dependent cellular cytotoxicity and antibody-dependent cellular phagocytosis mediated by anti-tumor mAbs are under investigation. Discussion: The combination of IPGG with ALM and RTX appeared safe and well tolerated overall with an ORR of 93% and a 64% CR/CRi rate. ABA concentrations did not correlate with clinical response to an IPGG containing regimen in these CLL patients. Data on functional implications of IPGG binding to leukemic B cells will be presented. Disclosures Bose: Biothera: Corporate stock options Other, Employment, Research Funding. Zent:Biothera: Research Funding. Ottoson:Biothera: Corporate stock options Other, Employment. Leonardo:Biothera: Corporate stock options Other, Employment. Ansell:Biothera: Research Funding.

Abstract Background: Historically, CLL patients with cytopenia were thought to have a poor prognosis and cytopenia is a key feature of CLL clinical staging systems. The implications of cytopenia in CLL could have changed because of improved diagnostic accuracy, increased recognition of early stage disease, and better treatments. Newer data suggest that the etiology of cytopenia determines its prognostic importance in CLL. Patients with cytopenia caused by autoimmune disease (AID) are less likely to have the poor prognosis associated with patients with bone marrow (BM) failure. To determine the prognostic significance of cytopenia in patients with CLL, we performed an observational study at Mayo Clinic Rochester (MCR). Methods: We studied all patients with CLL seen in the Division of Hematology at MCR from 1 January 1995 to 31 December 2004 (n = 1,750). Cytopenia (hemoglobin < 10 g/dL or platelet count < 100 × 09/L) was considered due to BM failure in patients with extensive BM involvement by CLL (< 20% residual myeloid tissue on BM biopsy) or reticulocytopenia without other causes persisting > 3 months after CLL therapy. Cytopenia was attributed to AID in patients with autoimmune hemolytic anemia (AIHA), immune thrombocytopenia (ITP), pure red blood cell aplasia (PRCA), or autoimmune granulocytopenia (AIG). Results: Median age at diagnosis of CLL was 63.7 years (69% male). Cytopenia occured in 423 (24.2%) patients. In 303 patients, cytopenia was due to CLL (228 BM failure and 75 AID). In 120 patients cytopenia was due to CLL related factors (splenomegaly, n = 11; possible AID, n = 18; treatment of CLL, n = 16) or non CLL causes (other malignancy, n = 12; iron deficiency, n = 11; anemia of chronic disease, n = 10; renal failure, n = 6; drugs effect, n = 4; surgical blood loss n = 4). In 28 (6.6%) patients the cause of cytopenia was not definitively determined. Of the patients with BM failure, 97 (43%) had cytopenia at CLL diagnosis (70% male, median age 63.3 years [range 32–95]), The AID patients the median age of CLL diagnosis was 66.7 years (range 30–85) with 79% male. AID diagnoses were AIHA (n = 41), ITP (n= 35), PRCA (n=8), and AIG (n=3); 9 patients had > 1 AID. Survival from diagnosis of cytopenia was significantly better for patients with AID (median 9.1 years) than BM failure (median 4.4 years, p < 0.001). AID patients had a longer survival from diagnosis of CLL (median 12.4 years) versus the rest of the CLL population (median 9.5 years, p = 0.020) but patients with BM failure at diagnosis had a worse prognosis (median 6.2 years, p < 0.001). Conclusion: We show that the etiology of cytopenia in CLL patients determines its prognostic importance. Anemia and thrombocytopenia caused by BM failure, but not AID, are associated with a significantly worse prognosis. These data show the importance of accurate determination of the etiology of cytopenia in all patients with CLL. Cytopenia in patients with AID is not a marker of advanced stage disease; these patients often need different management compared to those with BM failure. Cytopenia due to AID versus BM failure can be difficult to distinguish and a BM study should be done in all patients considered for treatment. Patients with cytopenia due to AID cannot be meaningfully classified by current clinical staging systems. We believe that efforts to review the NCI-WG 96 criteria are timely and should consider the etiology of cytopenia in CLL patients.

Abstract BACKGROUND: The study of rare diseases is limited by the uncommon nature of the conditions as well as the widely dispersed patient populations. Current rare disease registries such as the National Organization of Rare Diseases utilize centralized platforms for data collection; however because of their broad nature, these do not always capture unique, disease specific elements. Hairy Cell Leukemia (HCL) is a rare leukemia globally with approximately 900 new cases diagnosed in the US each year. The HCL Foundation undertook creation of a Patient Data Registry that collects data from multiple HCL Centers of Excellence (COE) around the globe to better understand the complications, treatment outcomes, disease subtypes, comorbid conditions, epidemiology, and quality of life of patients with HCL. METHODS: Investigators at The Ohio State University Department of Biomedical Informatics and Division of Hematology in collaboration with the HCL Foundation developed a Patient Data Registry (PDR) for the longitudinal capture of high quality research data. This system differs from other registries in that it uses a federated( rather than centralized) architecture, wherein data is queried and integrated in an on-demand manner from local registry databases at each participating site. Further, the data collected for use in the registry combines both automated exports from existing electronic health records (EHRs) as well as additional data entered via a set of web-based forms. All manually entered data comes from source documents, and data provenance spanning electronic and manually entered data is maintained via multiple technical measures. Patients may be enrolled at HCL COE, or, if they do not have access to a COE they may enroll via a web-based portal (www.hairycellleukemia.org). At this time due to regulatory requirements the web-based portal is available to US patients only. All data are de-identified (see Figure 1: De-Identification Workflow) which reduces regulatory burden and increases opportunities for data access and re-use. End users have access to data via a project-specific query portal. RESULTS: The Patient Data Registry has been deployed at The Ohio State University, Royal Marsden Hospital, and MD Anderson Cancer Center, and is undergoing deployment at the University of Rochester. Up to 25 international HCL COE may participate. In addition, US patients are actively entering the registry via the web-based portal. To date, 227 patients have been consented to the registry with 119 of these being via the web-based entry point. CONCLUSION: We created an international and web-based patient data registry which will enable researchers to study outcomes in HCL in ways not previously possible given the rarity of the disease. This work was made possible by research funding from the Hairy Cell Leukemia Foundation. Figure De-Identification Workflow Figure. De-Identification Workflow Disclosures Andritsos: Hairy Cell Leukemia Foundation: Research Funding. Anghelina:Hairy Cell Leukemia Foundation: Research Funding. Lele:Hairy Cell Leukemia Foundation: Research Funding. Burger:Pharmacyclics: Research Funding. Delgado:Gilead: Consultancy, Honoraria; Novartis/GSK: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Roche: Consultancy, Honoraria, Research Funding; Infinity: Research Funding. Jones:AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Pharmacyclics, LLC, an AbbVie Company: Membership on an entity's Board of Directors or advisory committees, Research Funding. Lozanski:Beckman Coulter: Research Funding; Genentech: Research Funding; Stemline Therapeutics Inc.: Research Funding; Boehringer Ingelheim: Research Funding. Montserrat:Morphosys: Other: Expert Testimony; Vivia Biotech: Equity Ownership; Gilead: Consultancy, Other: Expert Testimony; Pharmacyclics: Consultancy; Janssen: Honoraria, Other: travel, accommodations, expenses. Parikh:Pharmacyclics: Honoraria, Research Funding. Park:Genentech/Roche: Research Funding; Amgen: Consultancy; Juno Therapeutics: Consultancy, Research Funding. Robak:Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding. Tam:janssen: Honoraria, Research Funding; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees. Heckler:Hairy Cell Leukemia Foundation: Research Funding. Payne:Hairy Cell Leukemia Foundation: Research Funding.