Pixantrone-rituximab versus gemcitabine-rituximab in relapsed/refractory aggressive non-Hodgkin lymphoma.

UNLABELLED: We describe the rationale and design of the ongoing randomized, active-controlled, multicenter, Phase III study evaluating the efficacy of pixantrone and rituximab versus gemcitabine and rituximab in patients with diffuse large B-cell lymphoma or follicular grade 3 lymphoma, who are ineligible for high-dose chemotherapy and stem cell transplantation, and who failed front-line regimens containing rituximab. The administration schedule is pixantrone 50 mg/m(2) intravenously (iv.) or gemcitabine 1000 mg/m(2) iv. on days 1, 8 and 15, combined with rituximab 375 mg/m(2) iv. on day 1, up to six cycles. Pixantrone has a conditional European marketing approval for monotherapy in adults with multiple relapsed or refractory aggressive B-cell non-Hodgkin lymphoma. Our trial explores the efficacy of combining pixantrone with rituximab and completes postauthorization measures. TRIAL REGISTRATION NUMBER: NCT01321541

Exploring treatment decision-making in chronic myeloid leukemia in chronic phase

The introduction of tyrosine kinase inhibitors (TKIs) has transformed the treatment of chronic myeloid leukemia (CML). Each approved TKI has its own risk-benefit profile, and patients have choices across lines of therapy. Identifying the initial and subsequent treatment that will lead to the best possible outcome for individual patients is challenging. In this review, we summarize data for each approved TKI across lines of therapy in patients with CML in chronic phase, highlighting elements of each agent’s safety and efficacy profile that may impact patient selection, and provide insights into individualized treatment sequencing decision-making aimed at optimizing patient outcomes

Acceptability, Feasibility, and Efficacy Potential of a Multimodal Acceptance and Commitment Therapy Intervention to Address Psychosocial and Advance Care Planning Needs among Anxious and Depressed Adults with Metastatic Cancer

Background: Adults with metastatic cancer frequently report anxiety and depression symptoms, which may impact health behaviors such as advance care planning (ACP). Objective: The study leveraged acceptance and commitment therapy (ACT), an evidence-based approach for reducing distress and improving health behaviors, and adapted it into a multimodal intervention (M-ACT) designed to address the psychosocial and ACP needs of anxious and depressed adults with metastatic cancer. The study evaluated M-ACT\u27s acceptability, feasibility, and efficacy potential. Design: The study was designed as a single-arm intervention development and pilot trial. Setting/Subjects: The trial enrolled 35 anxious or depressed adults with stage IV cancer in community oncology clinics, with a referred-to-enrolled rate of 69% and eligible-to-enrolled rate of 95%. Measurements: M-ACT alternated four in-person group sessions with three self-paced online sessions. Acceptability and feasibility were assessed through enrollment, attendance, and satisfaction ratings. Outcomes and theorized intervention mechanisms were evaluated at baseline, midintervention, postintervention, and two-month follow-up. Results: Participant feedback was used to refine the intervention. Of participants starting the intervention, 92% completed, reporting high satisfaction. One-quarter did not begin M-ACT due to health declines, moving, or death. Completers showed significant reductions in anxiety, depression, and fear of dying and increases in ACP and sense of life meaning. In this pilot, M-ACT showed no significant impact on pain interference. Increases in two of three mechanism measures predicted improvement on 80% of significant outcomes. Conclusions: The M-ACT intervention is feasible, acceptable, and shows potential for efficacy in community oncology settings; a randomized trial is warranted

Pneumatosis intestinalis after adult liver transplantation

Pneumatosis intestinalis is an uncommon disorder characterized by an accumulation of gas in the bowel wall. We described three cases undertaking liver transplantation. The patients developed diarrhea in three cases and high fever in two. An abdominal X-ray and computed tomography scan demonstrated extensive pneumatosis intestinalis in the colon with pneumoperitoneum mimicking hollow organ perforation. However, the patients had no abdominal symptoms and there was no evidence of peritonitis. The infection work-up was negative except one case with cytomegalovirus antigenemia. After one week of conservative management including bowel rest and antibiotic therapy, their pneumoperitoneum resolved spontaneously without any complication. Pneumatosis intestinalis should be considered as a differential diagnosis after adult liver transplantation with patients suffering from watery diarrhea and fever. Pneumoperitoneum, air-density in mesentery and retroperitoneum in patients with pneumatosis intestinalis without signs of peritonitis improved with conservative management, which included bowel rest and antibiotic therapy

Baseline Physical and Mental Functioning Are Strong Predictors of Post-Stem Cell Transplant Function and Quality of Life.

Abstract Reported predictors of quality of life (QOL) after stem cell transplantation (SCT) are largely limited to biological variables. We used data from a large prospective study of autologous and allogeneic SCT recipients to test whether self-reported functioning also predicts later QOL. Surveys were collected at baseline and at 6 and 12 months following transplant and included sociodemographic variables, self-reported physical and mental functioning, and perceptions of health and recovery. Multivariate models for QOL variables at 6 and 12 months were constructed, considering baseline clinical variables (age, sex, type of transplant, disease status) and baseline QOL variables (the Short-Form 36 (SF36) physical (PCS) and mental health (MCS) scales, and a rating scale (RS)), controlling for clinical events (acute and chronic graft-vs.-host (GVHD), and relapse). Variables with p&lt;0.05 are reported. Of 300 patients who completed baseline surveys, 197 (111 allogeneic) completed 6 month surveys, and 175 (94 allogeneic) completed 12 month surveys. Patients reporting very good or excellent health at 6 months had higher baseline health rating scales (p&lt;.0001) and were less likely to have developed chronic GVHD (OR=.27, p=.03) or to be married/partnered (OR=.32, p=.003). Better physical health (higher PCS) at 6 months was associated with better baseline physical and mental health (p&lt;.0001 and p=.02), and absence of acute GVHD (p&lt;.0001) and relapse (p=.01). Baseline physical health was the strongest predictor (partial R2 =.20, model R2=.31). Better mental health (higher MCS) at 6 months was associated with better baseline mental health (p&lt;.0001), older age (p=.049), and not being married/partnered (p=.04). Baseline mental health was the strongest predictor (partial R2 0.17, model R2=.20). At 6 months, agreement with the statement “life is back to normal” was associated with baseline health rating scale (p&lt;0.0001); autologous SCT (p&lt;0.0001) and being female (p=.03) were also significant. Being able to “put the illness behind and get on with life” was associated with baseline MCS (p=0.0002), having an autologous SCT (p=0.0003) and being female (p=0.02). Agreement with “I have recovered from my SCT” was associated with absence of acute GVHD (p=0.004) and higher baseline health rating scale (p=0.03). At 1 year, baseline health and functioning remained the most predictive of all QOL outcomes, even though relapse and GVHD were also significant. The negative association with being married/partnered was no longer present, and the negative association with allogeneic transplant had largely disappeared. Good risk disease was associated with lower PCS (p=.02) at 1 year, but its explanatory power in the model was far less than baseline PCS. It was not associated with any other QOL outcome. When analysis was restricted to patients who underwent allogeneic transplant, baseline physical health was predictive of physical health at 6 months (p&lt;.0001) and 12 months (p&lt;.0001) and baseline mental health was predictive of mental health at 6 months (p=.0006) and 12 months (p&lt;.0001). Good disease risk was associated with being less likely to enjoy normal activities at 6 months (p=0.04) but not with any other QOL outcome. Relapse and cGVHD were associated with poorer QOL. In conclusion, baseline self-reported physical and mental health are stronger predictors of QOL after SCT than common baseline clinical predictors such as age and disease risk, independent of relapse and GVHD. &lt;/DEL&gt;</jats:p

Treatment Patterns and Outcomes of 159 Ibrutinib-Treated MCL Patients in the United States: A Retrospective Electronic Medical Record Database and Chart Review Study

Abstract Introduction Ibrutinib, a Bruton's tyrosine kinase inhibitor, was approved in the U.S. for the treatment of relapsed or refractory mantle cell lymphoma (MCL) in November of 2013. However, real-world data on ibrutinib use for the treatment of MCL is limited. The purpose of this study was to examine ibrutinib use, dosages, and reasons for treatment discontinuation among MCL patients treated in a community oncology practice setting. Methods The study population consisted of adult (≥18 year old) MCL patients treated with ibrutinib between November 1, 2013 and October 31, 2016, who were not enrolled in a clinical trial and had at least 2 visits to a US Oncology Network (USON) clinic. Patients with other primary cancers were excluded. Patient data were sourced from the USON's electronic health records system, iKnowMed (iKM)™. The structured iKM database provided information on demographics and clinical and treatment characteristics. Manual chart review was used to confirm ibrutinib treatment patterns. Duration of ibrutinib therapy (DOT), overall survival (OS), and progression-free survival (PFS) from systemic treatment initiation were estimated using Kaplan-Meier methods. Events were defined as death in the OS analysis, and progression or death in the PFS analysis. Patients were censored if their treatment was ongoing for DOT. Censors for OS and PFS were patients lost to follow up or those who did not experience a failure event within the study period. Results 159 eligible MCL patients were identified through iKM. The majority of patients were Caucasian (n=141, 88.7%), male (n=121, 76.1%), and diagnosed with Stage IV disease (n=117, 73.6%). Median follow-up for the population was 16.1 months. Approximately 7.5% (n=12) of patients received ibrutinib as first-line therapy (1L), compared to 54.1% (n=86) in 2L and 38.4% (n=61) in 3L or beyond. Median ibrutinib dose at initiation was 560mg (range: 140-700). During ibrutinib treatment, 16.4% (n=26) of patients experienced a dose reduction. Dose holds occurred in 30.2% (n=48), 66.7% (n=32) due toxicities. The overall discontinuation rate was 83.6% The primary reason for discontinuation was disease progression (n=46, 34.6%) followed by toxicities (n=34, 25.6%). Median DOT was higher for patients initiating treatment in 3L+ (14.9: 95% CI 8.8-17.1) compared to other lines. Median PFS was 19.6 (95% CI: 16.5-24.3) for the overall population and median OS was 25.8 months (95% CI: 19.9-not reached). Conclusions Our real-world findings on survival are consistent with those from clinical trials on ibrutinib in relapsed/refractory MCL, although our observed discontinuation rate (~84%) was higher than that of the trial (~58%), which had a similar median follow-up time (16.1 months vs. 15.3 months, respectively). Our findings provide additional data on MCL treatment patterns and patient outcomes in clinical practice. Disclosures Sharman: Acerta: Consultancy, Research Funding; Pharmacyclics, an AbbVie Company: Consultancy, Research Funding. Kabadi:AstraZeneca: Employment. Clark:McKesson Specialty Health: Employment, Equity Ownership. Amirian:McKesson Specialty Health: Employment. Andorsky:Celgene: Research Funding; CTI BioPharma: Consultancy, Research Funding; AstraZeneca: Consultancy; Genentech: Consultancy. </jats:sec

Programmed Death Ligand 1 Is Expressed by Non–Hodgkin Lymphomas and Inhibits the Activity of Tumor-Associated T Cells

Abstract Purpose: Programmed death ligand 1 (PD-L1) is expressed on antigen-presenting cells and inhibits activation of T cells through its receptor PD-1. PD-L1 is aberrantly expressed on some epithelial malignancies and Hodgkin lymphomas and may prevent effective host antitumor immunity. The role of PD-L1 in non–Hodgkin lymphomas (NHL) is not well characterized. Experimental Design: PD-L1 expression was analyzed in cell lines and lymphoma specimens by using flow cytometry and immunohistochemistry. Functional activity of PD-L1 was studied by incubating irradiated lymphoma cells with allogeneic T cells with or without anti-PD-L1 blocking antibody; T-cell proliferation and IFN-γ secretion served as measures of T-cell activation. Similar experiments were conducted using cultures of primary lymphoma specimens containing host T cells. Results: PD-L1 was expressed uniformly by anaplastic large cell lymphoma (ALCL) cell lines, but rarely in B-cell NHL, confined to a subset of diffuse large B-cell lymphomas (DLBCL) with activated B-cell features (3 of 28 cell lines and 24% of primary DLBCL). Anti-PD-L1 blocking antibody boosted proliferation and IFN-γ secretion by allogeneic T cells responding to ALCL and DLBCL cells. In autologous cultures of primary ALCL and DLBCL, PD-L1 blockade enhanced secretion of inflammatory cytokines IFN-γ, granulocyte macrophage colony-stimulating factor, interleukin (IL)-1, IL-6, IL-8, IL-13, TNF-α, and macrophage inflammatory protein-1α. In establishing cell lines from an aggressive PD-L1+ mature B-cell lymphoma, we also noted that PD-L1 expression could be lost under certain in vitro culture conditions. Conclusions: PD-L1 may thwart effective antitumor immune responses and represents an attractive target for lymphoma immunotherapy. Clin Cancer Res; 17(13); 4232–44. ©2011 AACR.</jats:p

Treatment Patterns and Outcomes of Patients with Relapsed or Refractory Follicular Lymphoma Treated with Idelalisib in a Community Oncology Setting

Introduction: Idelalisib (IDELA, Zydelig®) is the first-in-class PI3Kδ inhibitor and is approved in the U.S. as an oral monotherapy for relapsed / refractory follicular lymphoma (R/R FL) after at least two prior lines of systemic therapy. IDELA's regulatory approval was based on a phase 2, open-label clinical trial in 125 patients with R/R indolent non-Hodgkin's lymphoma (Gopal et al., NEJM, 2014) and outcomes in the FL subgroup were published by Salles et al. (Haematologica, 2017). The current study evaluates the characteristics and treatment patterns of patients treated with IDELA for R/R FL in a real-world setting. Methods: Adult patients diagnosed with R/R FL (grades 1, 2, and 3a) and treated with IDELA within the US Oncology Network (USON) between 7/1/2014 to 6/30/2018 were analyzed retrospectively. Patient data were obtained from USON's structured electronic health records' system, iKnowMed (iKM)TM. Manual chart review (ChR) was used to determine physician response and to confirm IDELA treatment patterns. Overall survival (OS) and progression-free survival (PFS) were estimated using Kaplan-Meier methods. Descriptive statistics were generated for outcomes of interest, including duration of therapy (DoT), median follow-up, and adverse event (AE) frequency. Results: A total of 124 patients with FL and prescribed IDELA were identified in iKM TM. After Chr confirming the diagnosis of follicular lymphoma diagnosis and initiation of IDELA, 88 patients were retained for analysis. Median age of patients was 68.9 years, with 52.3% female and the majority white and non-Hispanic (90.9% and 93.2%, respectively, Table 1). The most common regimens immediately prior to IDELA initiation were bendamustine + rituximab (22.7%), rituximab (17%), and rituximab maintenance (11.4%). Eighty-six (97.7%) patients had co-morbidities categorized as vascular (50%), endocrine (33%), respiratory (13.6%), or cardiac (12.5%). Thirteen (14.8%), 21 (23.9%), and 54 (61.4%) patients initiated IDELA in second line (2L), 3L, and &gt;4L, respectively. Baseline lab values at IDELA initiation were similar regardless of line of therapy (LOT). mDOT was 5.5 mos. for the entire population and was similar across all LOTs (4.1 mos., 6.1 mos., and 5.5 mos. in 2L, 3L, and &gt;4L, respectively). AEs were noted in 45.5% with the most common being gastrointestinal (31.8%) and dermatologic (10.2%). Respiratory and infectious AEs were noted in 2.3% and 1.1%, respectively, although Pneumocystis jirovecii pneumonia (PJP) prophylaxis was rarely prescribed (2.3%). Toxicity as a reason for IDELA discontinuation varied in frequency across LOT and was more common in 2L compared to 3L and &gt;4L (91.7% compared to 43.8% and 46.9%, respectively). With a median follow-up of 18.6 months for the population, the mPFS was 11.4 mos. [95%CI: 8.5,17.0] and mOS was 32.5 mos. [95% CI: 25.3,NR]. Stratified by LOT, median follow-up time, mOS, and mPFS were greater in 2L (30.8 mos., NR [95% CI: 27.37,NR], and 29.0 mos. [95% CI: 8.6,NR], respectively) than in 3L or &gt;4L (3L: 17.9 mos., 29.4 mos. [95%CI: 18.6,NR], and 17.5 mos. [95% CI: 6.1,NR]; &gt;4L: 16.5 mos., 25.3 mos. [95%CI: 13.5.,NR], and 8.6 mos. [95% CI: 6.1,12.6], respectively, Figures 1 and 2). Conclusion: Findings from this analysis suggest that R/R FL patients treated with IDELA in a real-world setting experience a similar mDOT and mPFS as those treated in the clinical trial setting (Salles et al., Haematologica, 2017). Patients treated in 2L demonstrated longer PFS and OS compared to later lines, but also experienced increased IDELA discontinuation due to toxicity, perhaps reflecting a lower incidence of progressive disease in earlier treatment lines, or a more immunocompetent population leading to higher rates of autoimmune AEs. Use of PJP prophylaxis in IDELA-treated patients was uncommon, an observation suggesting an opportunity for provider education. Our findings enhance available data on relapsed FL patient outcomes in real-world clinical practice and support the use of IDELA in patients with R/R FL after at least 2 systemic therapies. Disclosures Andorsky: Gilead: Research Funding; Genetech: Research Funding; CTI: Research Funding; AstraZeneca: Consultancy; Celgene: Research Funding. Chan:Gilead Sciences, Inc.: Employment, Equity Ownership. Clark:McKesson: Consultancy, Employment, Equity Ownership. Ruzicka:Gilead Sciences, Inc.: Employment. Robert:McKesson: Employment. Awan:Pharmacyclics: Consultancy, Research Funding; AstraZeneca: Consultancy, Speakers Bureau; Abbvie: Consultancy, Speakers Bureau; Janssen: Consultancy; Genentech: Consultancy; Sunesis: Consultancy; Gilead: Consultancy. OffLabel Disclosure: Idelalisib is a PI3 kinase inhibitor indicated for the treatment of patients with relapsed follicular B-cell lymphoma who have received at least two prior systemic therapies. Some patients in this observational study used Idelalisib after one prior systemic treatment. </jats:sec

Spectrum of Expression and Biological Activity of Programmed Death Ligand 1 (PD-L1) in Non-Hodgkin’s Lymphomas

Abstract Programmed Death Ligand 1 (PD-L1) is expressed on antigen presenting cells and serves to inhibit activation of T cells through its receptor, Programmed Death 1 (PD-1). PD-L1 is aberrantly expressed on epithelial malignancies and may prevent an effective host antitumor immune response. However, the pattern of expression and function of PD-L1 in non-Hodgkin lymphoma (NHL) is largely unknown. We examined 77 primary NHL tissue specimens and 16 NHL cell lines for expression of PD-L1. PD-L1 was detected by immunohistochemical staining in all 14 anaplastic large cell lymphoma (ALCL) specimens (both ALK+ and ALK-), and in 18 of 22 diffuse large B cell lymphomas (DLBCL). PD-L1 was expressed in all cases of Hodgkin’s, mediastinal B cell, and grey zone lymphoma, 50% of peripheral T cell lymphomas, 15% of follicular lymphomas, and 33% of mantle cell lymphomas. Among DLBCL cases subtyped into germinal-center B (GCB) and non-GCB using CD10, BCL-6, and MUM-1 (Hans et al, Blood2004;103:275), 8 of 12 (66%) GCB cases expressed PD-L1, compared to 10 of 11 (91%) of non-GCB cases (p=0.31). Among NHL cell lines, all 9 B cell lines were negative for PD-L1, as measured by flow cytometry, but all 5 ALCL cell lines were strongly positive. Therefore, we chose to focus on ALCL to study the role of PD-L1 in modulating anti-lymphoma T cell activity. PD-L1 expressed by ALCL was biologically active in that proliferation of allogeneic T cells co-cultured with Karpas 299 ALCL cells was significantly enhanced by blocking PD-L1 with monoclonal antibodies. To further study tumor-T cell interactions, malignant ascites from a patient with newly diagnosed ALK+ ALCL, containing approximately equivalent proportions of PD-L1-expressing tumor cells and tumor-associated T cells, was used as an autologous system. Secretion of interferon-γ after 3- or 5-day incubation of the T cell/tumor mixture with phytohemagglutinin (a polyclonal T cell activator) was increased four-fold in the presence of anti-PD-L1 antibody, as compared with control antibody or media alone. Secretion of other inflammatory cytokines, including IL-1, TNFα, IL-5, IL-13, and MIP1α, was also markedly increased with the addition of anti-PD-L1 antibody to the mixture of tumor cells and lymphocytes. In conclusion, PD-L1 is expressed in a broad array of non-Hodgkin lymphomas, particularly in ALCL. Blockade of tumor-associated PD-L1 promoted activation of adjacent T cells. PD-L1 may play a role in thwarting an effective antitumor immune response, and thus represents an attractive target for lymphoma immunotherapy using anti-PD-L1 or anti-PD-1 monoclonal antibodies. Heterogeneity of PD-L1 expression among DLBCLs may be related to GCB subtype or other biological properties, and these associations are being explored in a larger set of DLBCL cases. Table 1. PD-L1 expression by lymphoma subtype. Subtype Number PD-L1+ % Anaplastic large cell lymphoma 14 14 100% Diffuse large B cell lymphoma 22 18 82% T cell rich DLBCL 7 4 57% Follicular lymphoma 13 2 15% Mantle cell lymphoma 6 2 33% Mediastinal DLBCL 2 2 100% Hodgkin lymphoma 5 5 100% Grey zone lymphoma 1 1 100% Peripheral T cell lymphoma 7 4 57%</jats:p

Supplementary Methods, Table 1 from Programmed Death Ligand 1 Is Expressed by Non–Hodgkin Lymphomas and Inhibits the Activity of Tumor-Associated T Cells

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