ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA CONVEGNO INTERREGIONALE SIE TRIVENETO ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA UDINE – 17 NOVEMBRE 2006 FRANCESCO ZAJA - UDINE

Leucemia linfatica cronica: epidemiologia La più comune forma leucemica del mondo occidentale (20 -30% di tutte le leucemie) Età mediana alla diagnosi: 65 - 70 anni Incidenza complessiva aumenta con l’età: 30 nuovi casi/ 100.000/ anno oltre i 70 anni 40% età < 60 aa; 12% età < 50 aa Sopravvivenza mediana ~ 10-12 anni

LLC: caratteristiche biologiche Progressivo accumulo di linfociti B monoclonali scarsamente proliferanti (arrestati in G0-G1), funzionalmente incompetenti, con prolungata sopravvivenza. Iperspressione di bcl-2 (ipometilazione del DNA) con inibizione apoptosi. Alterazioni DNA Accumulo nel midollo osseo, sangue periferico, organi linfatici e in sedi extralinfatiche (più raramente)

LEUCEMIA LINFATICA CRONICA Morfologia atipica (PLL 10-50%) Morfologia tipica Morfologia atipica (PLL 10-50%)

Leucemia linfatica cronica: caratteristiche del decorso clinico La LLC presenta un decorso molto eterogeneo. Alcuni pazienti hanno un andamento estremamente indolente, che non richiede terapia per molti anni Altri possono andare incontro ad una crescita del clone leucemico relativamente rapida con una sopravvivenza di mesi o al massimo di pochi anni. Immunosoppressione e comorbidità infettiva Anemia emolitica (piastrinopenia) immune

LEUCEMIA LINFATICA CRONICA

CLL: YEAR OF DIAGNOSIS / SURVIVAL Sopravvivenza variabile Morfologia delle curve invariata Non plateau Ruolo palliativo del trattamento 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 > 1990 Survival 1980–1990 < 1980 4 8 12 16 20 Years E. Montserrat, 2003

1. DEFINIZIONE DEL RISCHIO ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA: 1. DEFINIZIONE DEL RISCHIO STADIO (RAI, BINET) DOUBLING TIME TIMIDINA KINASI BETA 2 MICROGLOBULINA CARIOTIPO STATO MUTAZIONALE GENI IMMUNOGLOBULINE ZAP-70 CD 38

PROBABILITY OF SURVIVAL Patients surviving (%) 100 80 60 40 20 13q deletion Patients surviving (%) 12q trisomy 11q deletion Normal 17p deletion 24 48 72 96 120 144 168 Months Döhner et al N Engl J Med 2000

Survival of CLL patients according to VH genes mutation and ZAP-70 positivity Damle et al. Blood 1999; Hamblin et al. Blood 1999 Crespo et al N Engl J Med. 2003

watch and wait fino a progressione sintomatica Malattia indolente: watch and wait fino a progressione sintomatica Dighiero et al NEJM 1998

Malattia sintomatica o progressiva: Terapia palliativa di contenimento Alchilanti (chlorambucil) Polichemioterapia Analoghi delle purine Fludarabina in monoterapia Fludarabina in associazione (ciclofosfamide, mitoxantrone) Anticorpi monoclonali (monoterapia, in associazione) Rituximab Campath-1H Trapianto di cellule staminali Autotrapianto Allotrapianto

Nuove terapie in fase di sperimentazione Lenalidomide Briostatina Flovopiridolo Oligonucleotidi anti-senso bcl-2 Anti CD40 …

ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA: 2. LA SCELTA TERAPEUTICA

FLUDARABINA VS CHLORAMBUCIL N. Pazienti 179 193 Regime 25 mg/m2 i.v. x 5gg /4 sett 40 mg/m2 p.o.x 1 gg /4sett RC 27% 3% RP 43% 40% PFS (mesi) 33 17 Rai et al,N Engl J Med 20000

Fludarabina versus CHOP e CAP Leporrier et al, Blood 2001 N. Pazienti 336 351 237 RC 40% 30% 15% RP 31% 42% 43% Sopravvivenza (mesi) 69 67 70

FLU-CY vs FLU in first-line tx of younger patients with CLL Pts 164 OR CR 83% 18% 94% 35% 0.001 < 0.001 Binet A CR 21% 46% 0.24 Binet B CR 8% 25% Binet C CR 15% 0.002 Progression free survival OR: overall response CR: complete response Eichhorst F et al 2006

FLU-CY vs FLU in first-line tx of younger patients with CLL Overall survival Eichhorst F et al 2006

3. ANTICORPI MONOCLONALI ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA: 3. ANTICORPI MONOCLONALI

ANTICORPI MONOCLONALI

UNCONJUGATED MONOCLONAL ANTIBODIES FOR CLL Monoterapia In associazione alla chemioterapia Consolidamento o mantenimento della risposta Purging in vivo nel trapianto di CS

RITUXIMAB IgG1, k Malignant B cell CD20 Killer CD20 Complement leukocyte CD20 Complement Rituximab Rituximab

RITUXIMAB IN RELAPSED/REFRACTORY CLL 375 mg/m2 weekly x 4 weeks Investigator Maloney McLaughlin Nguyen Piro* Winkler Foran Huhn Pts 3 33 15 7 9 29 28 CR (%) OR (%) 13 7 14 11 25 *8 infusions

In vitro: complement mediated lysis correlates with CD20 levels in B-CLL/PLL patients 100 80 60 40 20 –20 n=44 R=0.91 p<0.0001 Relative lysis (%) 33 B-CLL 5 PLL 6 MCL 0 200 400 600 800 1000 CD20 MFI Golay J, et al. Blood 2001

RITUXIMAB SYNERGY WITH FLUDARABINE Karpas 422 cells - complement-dependent lysis % dead cells 100 Control Fludarabine 80 Rituximab 60 Rituximab + fludarabine 40 20 24 hours 48 hours 72 hours Di Gaetano, Br J Haematol 2001

CALGB RETROSPECTIVE STUDIES Median age 64 63 % CR 20 38 % ORR 63 84 2 yr PFS 43 67 2 yr OS 81 93 Regimen Flu Flu + R Pts 179 104 PFS OS Byrd et al 2005

PFS (CALGB 9712): CONCURRENT VS SEQUENTIAL RITUXIMAB IN UNTREATED B-CLL 1.0 Sequential Concurrent 0.8 0.6 Proportion 0.4 Treatment Pts CR% OR% Sequential 53 28 77 Concurrent* 51 47 90 0.2 0.0 10 20 30 40 50 Months *Neutropenia grade 3-4: 74% vs 41% Byrd et al Blood 2003

FLU+CY+RITUXIMAB FOR CLL Cycle 1 Cycle repeats R: 375 mg/m2 (cycle 1) 500 mg/m2 (cycles 2–6) 1 2 3 4 7 14 21 28 F: 25 mg/m2 D a y s Cycles 2–6 C: 250 mg/m2 Cycle repeats 1 2 3 7 14 21 28 D a y s Keating et al. ASH 2002

FCR FOR RELAPSED AND REFRACTORY CLL Wierda et al. JCO 2005 Treatment Pts CR nPR PR OR Overall 177 25% 16% 32% 73% Alkylating a. 25 28% 12% 36% 76% Rituximab 7 29% FC 34 24% 15% 35% 74% F sensitive 78 33% 19% 77% F refractory 33 6% 9% 42% 58% Grade 3-4 Neutropenia 62% Thrombocytopenia 17% Anemia 24% Infections 16%

FCR FOR UNTREATED CLL Keating et al. JCO 2005 Characteristic FC (164) Eichhorst FC (34) Keating FCR (224) Median age 58 53 57 Rai 0-II III-IV 61% 39% 50% 66% 44% CR 35% 70% p<.05 nPR 29% 19% OR 94% 88% 95% CD5/19, end of Rx 12.8% 0.45% p<.05 Neutropenia 3-4° 38% 52% Median OS, months 73+ NR Untreated patients F FC FR FCR CR 20% 35% 38% 75%

TIME TO FAIL BY INITIAL RX p<.01 p<.001 M. Keating

SURVIVAL SALVAGE CLL F+P vs. FC vs. FCR M. Keating

CD52 ANTIGEN / CAMPATH-1H carbohydrate CD52, 12 amino-acids immunogenic epitope GPI anchor lipid rafts Campath-1H Rituximab CD52 MFI CD20 MFI M. Introna

RESULTS OF ALEMTUZUMAB IN CLL 30 mg three times weekly i.v. x 4-12 weeks study Prior Rx N° %CR %OR Österborg JCO1997 yes 29 4 42 Keating* Blood 2002 93 2 33 Rai JCO2002 24 *CAM 211 pivotal trial: TTP 4.7 m. all pts, 9 months responders OS 16 mths

CAMPATH-1H IN CLL Studio 005 : differente risposta a seconda dei tessuti esaminati Linfociti SP 90 % Linfociti M 45 % Linfoadenomegalie 34 % Splenomegalia 40 %

OR CR No 87% 72% < 5 cm 40% 17% > 5 cm 9% Lymphadenopathy Moreton et al. JCO 2005

TOLERABILITY OF ALEMTUZUMAB Infusion-related reactions most common Fever, rigors, nausea, vomiting, rash Mild to moderate, decreased after first week of therapy Ameliorated with acetaminophen and diphenhydramine Cytopenia Neutropenia (25%) and thrombocytopenia Infections Opportunistic (HSV, CMV, PCP) Incidence decreased with anti-infective prophylaxis Between week 4 and 8 and belonging 10-12 from end of therapy

CAMPATH-1H AS FIRST LINE TREATMENT OF CLL Patients 34 Age 66 Rai III-IV 69% Therapy 3-10-30 mg s.c in week 1 30 mg 3 x week s.c. (week 2 - 18) Prophylaxis Cotrimoxazol, Acyclovir, Fluconazol, CMV monitoring OR 87% CR 19% TTF 18 + months Fever 70% (68% 1-2°) Skin reactions 90% (88% 1-2°) Infections 4x CMV-reactivations, no severe bacterial infection Lundin et al, 2002

When is the maximum tumor reduction (PR/CR) achieved in responding patients? Treatment week / Cumulative response rate 6 wk 12 wk 18 wk Blood 100%* 100% 100% Lymph nodes 42% 69% 100% Spleen 29% 54% 100% Bone marrow 10% 45% 100% Total 22% 52% 100% * Median time to CR: 21 days Lundin et al, 2002

CAMPATH-1H IN GENETIC HIGH-RISK, FLUDA REFRACTORY CLL CR+PR VH unmutated 38% 11q- 33% 17p- 46% 11q- 17p- Stilgenbauer et al, NEJM 2002, Lugano 2005; Lozansky Blood 2004

LOW-DOSE CAMPATH IN CLL Reference Pts Schedule CR OR R-duration Laurenti 2005 12 10 mg x 3/week x 10 weeks, i.v. 2 (16%) 5 (41%) 10 (5-15+) Cortelezzi 2005 14 x 10 weeks, s.c. 3 (25%) 7 (50%) Reference Pts Toxicity Laurenti 2005 12 Neutropenia 4°: 2; anemia 3°: 3; thrombocytopenia 3°: 1. No bacterial infections. CMV reactivation: 66% Cortelezzi 2005 14 5 infections (1 fatal). 2 CMV reactivation

FLU-CAM IN RELAPSED/REFRACTORY CLL Cycle 1-4 (+2) (every 28 days): Fluda 30 mg/m2 days 1-3 Campath 30 mg days 1-3 Trimethoprim/sulfamethoxazole + Valacyclovir 36 patients Relapsed: 24 Refractory: 12 Elter et al., JCO 2005

30% 25% 83% 73% Therapy Flu-Cam Flu-Cy-R References Elter 2005 Wierda 2005 Patients (pre-treated) 36 177 Median age 61 59 Prior Rxs 2 Complete response 30% 25% Overall response 83% 73% Neutropenia 3-4 26% 62% Thrombocytopenia 3-4 17% Anemia 3-4 3% 24% Infections* 5% 16% *2 subclinical CMV reactivations 2 fungal pneumonia (aspergillus) 1 fatal E. Coli sepsis 1 Pseudomanas aeruginosa sepsis

Survival of CLL patient subgroups 1985–1997 Total Died Subgroup 609 129 Initial Dx 327 167 1st Rx 794 548 1st fludarabine Salvage 233 158 Fludarabine Refractory 100 80 60 Overall survival (%) 40 Failed alkylating agents 20 Failed fludarabine 24 48 72 96 120 144 Time (Months) M. Keating, MDACC

ATTUALITA’ NEL TRATTAMENTO DELLA LEUCEMIA LINFATICA CRONICA: 4. TRAPIANTO DI CELLULE STAMINALI

AUTOLOGO ALLOGENICO Trapianto Vantaggi No donor ↓ TRM Espianto “pulito” GVL Svantaggi Fallimento raccolta CS Contaminazione Ricadute. MDS TRM GVHD 100d allo-TRM: 31% Esteve et al, ASH 2001

RIC ALLOGRAFTING FOR CLL: EBMT SURVEY ON Treatment related mortality Leukemia 17 841-848; 2005

RIC TRANSPLANTATION FOR CLL Patients 64 Related 44 Unrelated 20 Age 56 (44-69) Unresponsive 53% TBI 2 Gy ± Fludara CSA + MMF Related Unrelated 2 ys relapse rate: 26% 2 ys TRM: 22% 2 ys OS: 60% Sorror et al JCO 2005

CLL Transplant Consensus: EBMT proposal for standard indications (iwCLL 2005) allo-SCT is a procedure with evidence-based efficacy in poor-risk CLL allo-SCT is a reasonable treatment option for younger patients with Non-response or early relapse (<12 mo) after purine analogue-based therapy Relapse <24 mo after purine analogue combinations or auto-SCT (+ HR genetics) p53 mutation with treatment indication Further indications and the optimum transplant strategy have to be defined in prospective trials.

17 (15 CLL + 2 SLL) Vivi Vivi RC DEC TRM DEC CLL Pazienti CLL AUTO UD 06/2006 17 (15 CLL + 2 SLL) Età mediana (range) 55 (37-64) Stato al trapianto: RC NRC/PRO Refractory 13 2 Salvataggio / Prima linea 2/15 SC source: PB 17 Follow up dal trapianto (range) 27 m (1-75) Vivi 13 (76%) Vivi RC 8 (47%) DEC TRM 2 (12%) DEC CLL

6 Pazienti CLL ALLO UD 06/2006 Età mediana (range) 56 (46-65) Precedenti linee di txs: 1 2 3 1 Stato al trapianto: RC NRC/PRO Refractory 4 SC source: M/PB 1/5 Donor: MRD/MUD 4/2 Regime: CONV/RIC 2/4 Follow up dal trapianto (range) 18 m (11-111)

TOTALE 6 6 (100%) RC: 4 Pazienti CLL ALLO UD 06/2006 Pts Alive Status Events RELATED 4 RC: 3 NRC: 1 HCV: 1 PRO: 2 UNRELATED 2 RC: 1 CONVENTIONAL RC: 2 RIC NRC: 2 PRO: 2) TOTALE 6 6 (100%) RC: 4

CLL: YEAR OF DIAGNOSIS / SURVIVAL CONCLUSIONI -1 CLL: YEAR OF DIAGNOSIS / SURVIVAL ? 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 > 1990 Survival 1980–1990 < 1980 4 8 12 16 20 Years E. Montserrat, 2003

CONCLUSIONI -2 Possibilità di ottenere CR nel 50-70% Qualità della CR migliorata Chemo-immunoterapia (Rituximab/ Campath-1H) ed il trapianto di cellule staminali può portare a risposte molecolari La scelta terapeutica deve essere guidata da fattori clinici (età) e prognostici

Studio pilota di fase II per la valutazione di una strategia terapeutica diversificata sulla base del profilo biologico in pazienti con Leucemia Linfatica Cronica (LLC) in stadio avanzato e/o progressiva di età <60 anni. Protocollo GIMEMA LLC0405 EudraCT Number 2005-002476-15

CURATIVE STRATEGY FOR CLL: M.KEATING Induction Flu-CY + Rituximab PCR- PCR+ Consolidation Campath-1H PCR- PCR+ Eradication Transplant