Mediterranean School of Oncology DIAGNOSTIC AND THERAPEUTIC BURNING QUESTIONS ON LYMPHOPROLIFERATIVE DISEASES Rieti 27-29 Ottobre 2006 DALLA CHEMIOTERAPIA AGLI ANTICORPI MONOCLONALI, AGLI INIBITORI TIROSINCHINASICI NEL TRATTAMENTO DEI LINFOMI A CELLULE T PERIFERICHE Lorenzo Falchi Università degli Studi di Perugia Sez. di Medicina Interna e Scienze Oncologiche

CLASSIFICAZIONE W.H.O. / EORTC LINFOMI A CELLULE T PERIFERICHE CLASSIFICAZIONE W.H.O. / EORTC

LINFOMI A CELLULE T PERIFERICHE CARATTERI GENERALI Rappresentano il 10-15% di tutti i LNH nel Mondo Occidentale; Condividono una origine post-timica del clone neoplastico; Mostrano un ampio spettro di variabilità morfologico-immunofenotipica; Mostrano nella maggior parte dei casi un comportamento aggressivo (eccezioni: cALCL; MF) in assenza di un preciso correlato morfologico-biologico-clinico

BURNING QUESTIONS! La comprensione della biologia LINFOMI A CELLULE T PERIFERICHE BURNING QUESTIONS! La comprensione della biologia e la definizione di una ottimale strategia terapeutica è stata per i linfomi a cellule T periferiche (PTCL) meno ben sviluppata ed è quindi meno evoluta, rispetto a quanto si è verificato per i LNH a cellule B per: RARITÀ ETEROGENEITÀ MODALITÀ DI CONDUZIONE DEGLI STUDI CLINICI

ETEROGENEITÀ ANCHE PROGNOSTICA! LINFOMI A CELLULE T PERIFERICHE Valore prognostico del fenotipo T-cellulare Numerosi ampli studi hanno recentemente dimostrato che il fenotipo T-cellulare ha DI PER SÈ un impatto negativo sulla sopravvivenza globale dei pazienti Studi precedenti, privi di adeguati strumenti classificativi, avevano indicato una prognosi equivalente per i pazienti con LNH B- e T cellulare L’inclusione di sottotipi a prognosi più favorevole (i.e. ALCL) nel gruppo dei PTCL può aver sottostimato il reale comportamento clinico della maggior parte di questi linfomi. ETEROGENEITÀ ANCHE PROGNOSTICA!

LINFOMI A CELLULE T PERIFERICHE BURNING QUESTIONS! “There is no reason to expect that the same drugs would be optimal for patients with peripheral T-cell lymphoma – or that all subtypes of peripheral T-cell lymphoma would benefit from the same drugs.” J.O. Armitage et al. Ann Oncol. 2004 15: 1447-9 (Editorial)

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito Necessità di scores prognostici con potere discriminativo maggiore vs. IPI?

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito Necessità di scores prognostici con potere discriminativo maggiore vs. IPI?

Peripheral T-cell lymphomas: Initial features, natural history, and prognostic factors in a series of 174 patients diagnosed according to the R.E.A.L. Classification Overall survival of the 174 patients with PTCL included in the present series. 38% (95% CI: 28-48) A. Lopez-Guillermo et al. Ann Oncol. 1998; 9: 849-855.

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito Necessità di scores prognostici con potere discriminativo maggiore vs. IPI? Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito Necessità di scores prognostici con potere discriminativo maggiore vs. IPI? Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate

Prognostic Significance of Anaplastic Lymphoma Kinase (ALK) Protein Expression in Adults With Anaplastic Large Cell Lymphoma Survival of T-cell/null cell anaplastic large cell lymphoma (ALCL) patients by anaplastic lymphoma kinase (ALK) expression. ALK+ ALK- Randy D. Gascoyne et al. Blood. 1999; Vol 93, No 11: 3913-3921

Prognostic Significance of Anaplastic Lymphoma Kinase (ALK) Protein Expression in Adults With Anaplastic Large Cell Lymphoma BURNING QUESTIONS: Very few data are available concerning the clinical and pathological features that are useful for predicting outcome in ALCL. Interpretation of these data is further confounded by the lack of precise criteria to distinguish primary cutaneous ALCL from systemic ALCL. Even less is known about the prognostic significance of NPM-ALK/p80 protein expression. Although three reports have suggested that NPMALK/p801 cases of ALCL are associated with a younger median age at diagnosis and an improved survival, no treatment details were provided and, more importantly, these studies did not perform multivariate analysis. Randy D. Gascoyne et al. Blood. 1999; Vol 93, No 11: 3913-3921

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Necessità di scores prognostici con potere discriminativo maggiore vs. IPI? Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito

PER IL TRATTAMENTO PRIMARIO DEI PTCLs LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Necessità di scores prognostici con potere discriminativo maggiore vs. IPI?

LINFOMI A CELLULE T PERIFERICHE BURNING QUESTIONS! “There is no reason to expect that the same drugs would be optimal for patients with peripheral T-cell lymphoma – or that all subtypes of peripheral T-cell lymphoma would benefit from the same drugs.” J.O. Armitage et al. Ann Oncol 15: 1447-9 (Editorial)

TERAPIA DI PRIMA LINEA NECESSITA’ DI NUOVI APPROCCI TERAPEUTICI! LINFOMI A CELLULE T PERIFERICHE TERAPIA DI PRIMA LINEA NON È STATO ANCORA INDIVIDUATO UN REGIME TERAPEUTICO CHE POSSA CONSIDERARSI IL “GOLDEN STANDARD” PER IL TRATTAMENTO PRIMARIO DEI PTCLs CHOP e CHOP-like: terapia di scelta nella maggior parte dei pazienti con PTCL di nuova diagnosi, ma risultati uniformemente non soddisfacenti Regimi chemoterapici più intensivi non chiaramente superiori vs. schema CHOP NECESSITA’ DI NUOVI APPROCCI TERAPEUTICI! Alcuni sottotipi istologici di PTCL mostrano un comportamento biologico-clinico peculiare e necessitano di strategie terapeutiche differenziate Ruolo dell’AUTO- e dell’ALLOtrapianto: non ancora stabilito Necessità di scores prognostici con potere discriminativo maggiore vs. IPI?

NUOVI APPROCCI TERAPEUTICI LINFOMI A CELLULE T PERIFERICHE NUOVI APPROCCI TERAPEUTICI Analoghi nucleosidici Immunotossine HDACi IMMUNOTERAPIA Gemcitabina Anti-CD25 (radiolabeled) Ara-G SGN30 Pentostatina MDX-060 Depsipeptide 5F11 Denileukin difitox KM2760-AntiCCR4 Alemtuzumab Alemtuzumab + CT

ANALOGHI NUCLEOSIDICI LINFOMI A CELLULE T PERIFERICHE ANALOGHI NUCLEOSIDICI Author Drug Mech. of action Pt n. Schedule Outcome Sallah gemcitabine Nucleoside analog, pyridine anti-metab: non-specific DNA synthesis inhibition 10 (4 PTCLs) IV, 1200 mg/ms; D1, 8, 15 every 28 days; 2-4 cy ORR: 60% Myron 506U78 Pro-drug of Ara-G (deoxyguanosine analog): toxic to T-cells 19 (8 PTCLs) IV, 1,5 gr/ms; D1, 3, 5 every 21 days 2-8 cy ORR: 10,5%, 15 pts dead, median OS: 3m Tsimberidou (MDACC) pentostatin inhibits adenosine deaminase 42 (4 PTCLs +1 ATLL) 3 Ds every 3 W. 1) 0: 5.0 mg/m2; 2) -1: 3.75 g/m2; 3) -2: 2.8 mg/m2; 4) +1: 6.25 g/m2 ORR: 100% 2ys OS: 53%

INIBITORI DELLE HDAC IMMUNOTOSSINE LINFOMI A CELLULE T PERIFERICHE INIBITORI DELLE HDAC Author Drug Mechanism of action Pt n. Schedule Outcome Piekarz Depsipeptide Inhibitor of histone deacetylation; differentiating agent 19 14 mg/ms; 4 h inf; D 1, 8, 15 every 28 days Phase II; ORR: 26% IMMUNOTOSSINE Author Drug Mechanism of action Pt n. Schedule Outcome Dang Denileukin difitox* Targets tumor cells expressing IL-2R 14 (7 CD25+, 7 CD25-)* 18 μg/Kg/day X5 days every 3W; up to 8 cy ORR: 50% (CR 14%, PR 36%) *fusion protein combining the enzimatically active domain of diphteria toxin and the full-lenght sequence of IL-2. ** CD25-positivity defined as 10% or more of tumor cells expressing detectable CD25

IMMUNOTERAPIA LINFOMI A CELLULE T PERIFERICHE Author Drug Mechanism of action Pt n. Schedule Outcome Waldmann Anti-CD25 yttrium-90 labeled Anti-Tac binds to IL-2Rα, preventing interaction with IL-2* 18 (16 evaluable) IV injection; phase I study: dose escalation**; phase II: 10 mCi 90Y anti-Tac per cycle ORR: 56% Forero-Torres Anti-CD30 Chimeric mAb which recognizes the CD30 Ag 5 (ALCL) IV, 6 mg/Kg weekly ORR: 33% Well tolerated IV injection; phase I study:dose escalation; phase II: 10-15 mg/Kg weekly for 4 cy Ansell Anti-CD30 Fully human anti-CD30 IgG1k mAb 5 (ALCL) ORR: 33% Well tolerated Ishida KM2760 Defucosylated chimeric anti CCR4; ADCC Cell lines, primary tumor cells Preclinical studies *Resting normal T cells, B cells and monocytes do not display IL-2Rα. In contrast, this receptor subunitis expressed by a proportion of the abnormal cells in certain forms of leukemia and lymphoma **Start at 5 mCi, increase by 5 mCi every cycle until MTD

Alemtuzumab CD52 is a nonmodulating antigen which is expressed at high density on > 95% of all normal and malignant B and T lymphocytes, monocytes and macrophages, but not on hemopoietic stem cells. Alemtuzumab is a humanized immunoglobulin G1 (IgG1; CDR grafted) anti-CD52 monoclonal antibody that binds to the cell membrane of more than 95% of all normal human blood lymphocytes, as well as to most B- and T-cell lymphomas. In vitro: complement-mediated lysis, antibody-dependent cell cytotoxicity (ADCC) and apoptosis. It is unclear which of these mechanisms is most important for the therapeutic activity of this antibody in vivo. Malignant T cells appear to express extraordinarily high numbers of CD52 cell surface molecules (approximately 500 000 molecules per lymphocyte). Thus, T-cell lymphomas, including PTLs, may be particularly suitable for therapy with alemtuzumab

A pilot study of alemtuzumab (anti-CD52 monoclonal antibody) therapy for patients with relapsed or chemotherapy-refractory peripheral T-cell lymphomas CONCLUSIONS I: Alemtuzumab may have high antitumor activity in PTL. The rate of remissions in this heavily pretreated, poor-prognosis group of patients is promising. Responses were obtained at all tumor sites, including lymph nodes However, the infectious (5 patients dying from infectious complications) and hematologic (more pronounced than in previous alemtuzumab studies in B-CLL, T-PLL, and MF/SS) toxicity observed was unacceptably high, leading to an early closure of the study. after 14 of the planned 25 patients had been enrolled Gunilla Enblad, Blood. 2004;103: 2920-2924

A pilot study of alemtuzumab (anti-CD52 monoclonal antibody) therapy for patients with relapsed or chemotherapy-refractory peripheral T-cell lymphomas CONCLUSIONS II: Alemtuzumab, in combination with the emerging availability of technologies that help restore T-cell functions and numbers (i.e. antibodies to CD3 and CD28), may hopefully enhance the safety of CD52-targeted therapy in forthcoming clinical trials. Alternatively, lower dosages of alemtuzumab could be explored to improve the safety of alemtuzumab therapy in PTL patients. Further studies with alemtuzumab in PTL are warranted in patients with less advanced disease and earlier in the disease course. The safety and efficacy of alemtuzumab as a component of first-line therapy for PTL also needs to be investigated. Gunilla Enblad, Blood. 2004;103: 2920-2924

Preliminary observations of a phase II study of reduced-dose alemtuzumab treatment in patients with pretreated T-cell lymphoma RESULTS AND CONCLUSIONS: Escalating dosage: 3 mg d 1; 10 mg d 3; then 10 mg, 3 times a week, for a maximum of 4 weeks. ORR: 60%, 2 (20%) CR, and 4 (40%) PR. The median duration of response was 7 months (range: 2-10). No grade 3-4 anemia/ neutropenia/ thrombocytopenia. Response rates are broadly in line with those achieved utilizing conventional alemtuzumab schedules. Alemtuzumab at lower doses increases safety while maintaining effectiveness. Pier Luigi Zinzani, haematologica 2005; 90:702-703

Reduced intensity conditioning and allogeneic stem cell transplantation after salvage therapy integrating alemtuzumab for patients with relapsed peripheral T-cell non-Hodgkin’s lymphoma GG Wulf. Bone Marrow Transplantation (2005) 36, 271–273.

Reduced intensity conditioning and allogeneic stem cell transplantation after salvage therapy integrating alemtuzumab for patients with relapsed peripheral T-cell non-Hodgkin’s lymphoma CONCLUSIONS: Combining anti-CD52 antibody therapy with chemotherapy in peripheral T-NHL appears feasible. As for the efficacy of alemtuzumab against T-NHL in this setting, no firm conclusions can be drawn: may help patients with T-NHL to achieve PR prior to definitive HDS followed by SCT?

PROSPETTIVE FUTURE - 1 LINFOMI A CELLULE T PERIFERICHE The comparison of peripheral T-cell lymphoma with normal samples revealed a subset of 17 and 35 significantly differentially expressed genes between all peripheral T-cell lymphoma tumors and normal T lymphocytes or reactive lymph nodes, respectively Some of these genes represented immune response proteins, and some of them could represent tumoral markers characterizing T-cell ymphomas.

DIREZIONI FUTURE - 1 LINFOMI A CELLULE T PERIFERICHE On the basis of genes that are differentially expressed between lymphoblastic T-cell lymphoma and peripheral T-cell lymphoma tumors, we identified genes related with NF-KB signaling pathway, both proteins necessary for the activation of this factor as could be some interleukin receptors such us IL2RB, LTB, tumor necrosis factor-induced proteins, PRKCD, RELB, or MAP3K14 (NIK), or genes that are targets of the transcriptional activity of NF-B such as VCAM1, BIRC3, JUNB, or MMP9. As a whole, we found that NF-B pathway is not activated in lymphoblastic T-cell lymphomas, although it seems to be hyperactivated in peripheral T-cell lymphoma tumors. B Martinez-Delgado Clin Cancer Res, 10, 4971–4982, 2004

DIREZIONI FUTURE - 2 LINFOMI A CELLULE T PERIFERICHE Gene expression profiling identifies molecular subgroups among nodal peripheral t-cell lymphomas PTCLUS divided into the three subgroups: U1: expression of cyclin D2 and few reactive cells U2: with some overlap with U1 but also associated with overexpression of genes involved in T-cell activation and apoptosis including NF-κB1 and BCL2; U3 (including the previously defined “Lennert’s lymphoma”): overexpression of histiocytic markers in addition to genes involved in the IFNγ/JAK/STAT pathway. B. Ballester

DIREZIONI FUTURE - 3 LINFOMI A CELLULE T PERIFERICHE Gene expression analysis of peripheral t-cell lymphoma not otherwise specified reveals the existence of two subgroups related to different cellular counterparts Comparison with the gene expression profiles of purified normal T-cell subpopulations, shows that PTCLUS cells are more related to activated T cells, both CD4+ and CD8+. Of interest was overexpression of PDGFRA, confirmed by IHC, which may be a potential therapeutic target. P. Piccaluga

Expression of platelet-derived growth factor receptor in peripheral T-cell lymphoma not otherwise specified BACKGROUND: Platelet-derived growth factor (PDGF) induces mitosis in fibroblasts, smooth-muscle cells (wound healing) and other cells. Ever since the discovery 20 years ago that the transforming retroviral v-sis oncogene is derived from the platelet-derived growth factor (PDGF) B chain gene, PDGF signaling has been an interesting target for cancer treatment. In addition to its role in autocrine growth stimulation of tumor cells, PDGF has also been suggested to regulate tumor stroma fibroblasts and tumor angiogenesis

Expression of platelet-derived growth factor receptor in peripheral T-cell lymphoma not otherwise specified BACKGROUND: in several tumours, aberrant PDGF or PDGFR signalling constitutively activates a cell-signalling cascade. Moreover, inhibition of PDGFR activity can lead to tumour regression.

Genes differentially expressed in healthy and neoplastic samples. Expression of platelet-derived growth factor receptor in peripheral T-cell lymphoma not otherwise specified Gene expression profile of 17 patients with peripheral T-cell lymphoma not otherwise specified and 15 samples of purified T lymphocytes from healthy donors Genes differentially expressed in healthy and neoplastic samples. PDGFRα was overexpressed by four fold in peripheral T-cell lymphoma not otherwise specified. Pier Paolo Piccaluga et al. Lancet Oncol 2005; 6: 440

Expression of platelet-derived growth factor receptor in peripheral T-cell lymphoma not otherwise specified Gene expression profile of 17 patients with peripheral T-cell lymphoma not otherwise specified and 15 samples of purified T lymphocytes from healthy donors We then searched tissue samples for presence of PDGFRα by applying a polyclonal antibody to tissue microarrays containing samples from the 17 patients who had gene-expression profiling On immunoalkaline-phosphatase staining, neoplastic cells showed that the cytoplasm of all tested cases were positive for PDFGR. Because PDGFR is a potential target for imatinib, our findings might have important pathogenetic and clinical implications. Pier Paolo Piccaluga et al. Lancet Oncol 2005; 6: 440

The points of intervention of PDGF receptor signaling. TK inhibitor