Report on the 56th ASH Annual Meeting, San Francisco, 4–9 December 2014
Alberto Agazzi
Hematoncology Division, European Institute of Oncology, Milan, Italy
Correspondence to: Alberto Agazzi. Email: alberto.agazzi@ieo.it
Abstract
The 56th annual ASH (American Society of Haematology) meeting was held in San Francisco (CA). More than 3,000 abstracts were selected for presentation due to the huge amount of information from basic science to clinical experience. The future direction in haematoncology is targeted therapies for most diseases; for instance, anti-PD-1 and CAR-T cells in lymphoproliferative disorders and novel immunomodulatory agents active in the contest of bone marrow milieu in multiple myeloma. On the other hand, in aggressive haematological diseases (AML, ALL), clinical studies demonstrated the feasibility of a more intensive chemotherapy approach in older patients.
Keywords: chimeric antigen receptors, intensive chemotherapy, PD-1 inhibitors, target therapy
Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
AML in older adults
Acute myeloid leukaemia (AML) is a disease of older adults with a median age of 67 years at presentation. In the past, only one-third of older patients (> 65 years old) received definitive therapy due to concern about their overall fitness and potential treatment-related mortality. However, epidemiological data have shown that older patients with AML (up to 80 years old) have more tolerance and survival rate after therapy than their untreated counterparts [1]. Currently, therapeutic options for elderly patients include intensive chemotherapy with cytarabine and anthracycline backbone, hypomethylating agents (decitabine and azacitidine), low-dose cytarabine, investigational agents and supportive care with hydroxyurea and transfusions [2]. Preliminary results suggest benefit from reduced intensity allogeneic haematopoietic cell transplantation (HCT) in selected patients (60–80 years old) [3, 4]. In the absence of prospective randomized trials comparing HCT and chemotherapy, the decision to recommend HCT is based upon retrospective analysis of the risk of relapse and non-relapse mortality after each approach. It is strongly evidenced that pre-HCT comorbidities can predict HCT-related morbidity and mortality. Age alone does not appear predictive, and if the risk of relapse with chemotherapy is high, it should not be the sole basis for deciding against HCT. Disease status and pretreatment cytogenetics (FLT3-TID, NPM-1, CEPB-α) are the main factors predicting relapse, and these are likely to be supplemented by incorporating other molecular markers and the level of MRD after chemotherapy [5]. HLA-matched related and unrelated donors grafts seem to be better than those from other donor sources. Donor age is of no clear significance.
AML (Intermediate risk therapy)
Research in molecular genetics has been crucial in deciphering the molecular heterogeneity of AML, in particular the subset of patients with intermediate risk cytogenetics [7]. At present, NPM1, CEBPA, and FLT3 have entered into clinical practice [8], although FLT3-inhibitors, including lestaurinib, sorafenib and midostaurin (phase 3 trials), crendanib, quizartinib (phase 2), are under investigation. The addition of immunoconjugate gentuzumab ozogamicin to standard induction therapy (7 3) has been shown to improve outcome [8, 9]. A common standard for post-remission therapy is repeated cycles of intermediate high-dose cytarabine. Allogeneic transplantation may offer a survival benefit for many patients in this setting. Many novel agents targeting mutant leukaemia drivers of deregulated pathways are in clinical development (DNMT3A, IDH1, IDH2, ASXL1, TET2, RUNX1).
Myelodisplastic syndromes
Myelodisplastic syndromes (MDS) are the most commonly diagnosed myeloid disease with >15,000 new cases yearly in western countries [10].
Prognostic scoring systems divide patients into those with lower risk and those with higher risk MDS. Although treatment goals for patients with low-risk disease focus on minimizing transfusions and optimizing quality of life, the treatment goal for high-risk patients is to delay transformation into acute leukaemia and to prolong survival. In low-risk patients, cytopaenias are treated with erythropoiesis-stimulating agents or growth factors such as thrombopoietin mymetics [11]. For patients with del (5q-) or those who fail these initial approaches, lenalidomide may be tried, as can experimental agents [12]. Low-risk patients with multiple cytopaenias may be treated with immunosuppressive drugs or low-dose hypomethylating agents [13]. For patients with high-risk MDS, hypometthylating agents are the main initial treatment approach, but novel molecules are being developed for MDS patients who have failed when treated by hypomethylating drugs:
• Azacitidine (AZA) Lenalidomide (rand. phase 2, N 280) OR 72% CR 44%.
• AZA HistoneDeacetylase inhibitor (HDI) Vorinostat (rand. phase 2, N 280) OR 70%, CR 42%.
• AZA HDI Pracinostat (rand. phase 2, N 100 ongoing; in phase 1 OR 89%, CR 78%).
• AZA PI3K/PLK1 inhibitor Volasertib (phase 1 ongoing).
• PI3K/PLK1 inhibitor rigosertib (rand. phase 2 in hypomethylating agents failure. Median survival of 8.2 versus. 5.8 mo for control arm of best supportive care cytarabine).
• Decitabine DNA methyltranserase depletion anti-cancer quinolone-derivative vosaroxin (phase 1 and 2 ongoing. Of 16 patients, OR 81%).
Double-hit lymphomas novel treatment strategy
Double-hit lymphomas (DHLs) are a heterogeneous group of mature B-cell lymphomas that harbour concurrent rearrangements of MYC and BCL-2 or occasionally BCL-6 [14]. They are associated with a very aggressive clinical behaviour and poor outcome after standard therapy (R-CHOP): OS less than 2 years [15]. It is also known that a significant proportion of diffuse large B-cell lymphomas (DLBCL) case have high coexpression of MYC and BCL-2 by IHC (double expressors): they are also associated with poor outcome after R-CHOP. Alternative therapies, (DA-EPOCH-R)and R-HyperCVAD, are under investigation and new approaches such as alternative immunotherapies and novel small molecules inhibitors (anti-MYC, anti-BCL-2 and BCL-6) [16].
Chronic lymphocytic leukemia
Chronic lymphocytic leukemia (CLL) is characterized by a relatively small number of recurrent genetic alterations. Acquired defects in the p53 pathway, activating mutations of NOTCH1 and dysfunctional mutations of SF3B1 and BIRC3 identify patients with higher risk of progressive disease, poorer response to conventional therapies and shorter survival [17]. The patients with this CLL pattern should be candidates for a novel approach such as TKIs, BCL-2 inhibitors, monoclonal antibodies and immunological therapies including allogeneic transplantation and chimeric receptor-targeted T-cell.
Follicular lymphoma and microenvironment
Immune and non-immune microenvironmental factors play a crucial role in the progression, transformation and resistance to therapy in follicular lymphoma (FL). We have recently experienced the development of several therapies targeting the microenvironment with activity in relapsed disease (immunomodulatory drugs, immune checkpoint inhibitors, immunoconjugates and small molecules inhibitors). These approaches are now at different stages of clinical development ranging from early trials in relapsed disease to phase 3 studies in an upfront setting now allow for the building of ‘chemo-free’ regimens.
Lenalidomide (phase 3 combination trials with monoclonal antibody and chemoimmunotherapy) is used as immunomodulatory drugs [18]. The immune checkpoint inhibitors used are ipilimumab (CTLA-4 inhibitor, phase I completed and combination trial considered) [19], pidilizumab, nivolumab, MK-3475 (PD-1 inhibitors, phase 2 single agent and combination trials) [20]. Brentuximab vedotin (anti-Cd30 Ab) is used as immunoconjugates, which includes phase-2 study. Ibrutinib (BRUTON’s TKI) is used as BCR pathway inhibitors, which include phase 2 and 3 including combinations [21].
Multiple myeloma
Multiple myeloma (MM) is a unique cancer paradigm for investigating the mechanisms involved in the transition from a premalignant condition (MGUS) into a malignant disease (MM). The relationship among malignant plasma cells, the microenvironment and the genotypic characteristics of the MM clone plays a critical role in the outcome of the disease [22]. Although MM remains an incurable disease, the improved survival rates achieved over the past decade reflect the enhanced therapies (new generation IMIDS and proteasome inhibitors) for both upfront and relapsed disease. Moreover, new classes of agents are now in the development for MM [23]: oral proteasome inhibitors (Ixalomib and oprozomib), monoclonal antibodies (anti-CD 38 daratumumab and anti-CD138 Indatuximab), hystonedeacetylase inhibitors (panobinostat), AKT inhibitors (afuresertib), CDK inhibitors (dinaciclib) and immune therapies (PD-1 and PDL1).
Conclusion
Immunotherapy was a big topic at ASH 2014 and novel therapies that harness the body’s own immune cells to attack cancer cells took centre stage. Anti-PD1 therapy was discussed extensively as a way of enabling the immune system to attach tumour cells. Also genetically engineered chimeric antigen receptor T (CAR T) cells were shown to be safe in patients with relapsed and treatment-resistant blood cancers. Genetics was also an important topic with presentations on sequencing circulating DNA as a diagnostic tool and looking for genetic mutations which may be drivers in promoting the disease. Again epigentics came to fruition this year and this was discussed extensively—the epigenetic state of cells within these malignancies will become more important. Finally, some new molecules, such as the monoclonal antibody daratumumab, appeared to work well with a variety of backbone regimens in multiple myeloma. Overall, in haematoncology, it is hoped that the new therapies will be entered into the clinic soon.
References
1. Juliusson G, Antunovic and Derolf et al (2009) Age and acute myeloid leukemia: real world data on decision to treat and outcomes from the Swedish Acute Leukemia Registry Blood 113 4179–4187 DOI: 10.1182/blood-2008-07-172007
2. Deschler B, de Witte T, Mertelsmann R and Lubbert M (2006) Treatment decision-making for older patients with high-risk MDS or acute myeloid leukemia: problems and approaches Hematologica 91 1513–1522
3. Gyurkocza B, Storb R and Storer BE et al (2010) Nonmyeloablative allogeneic hemopoietic cell transplantation in patients with acute myeloid leukemia J Clinical Oncol 2859–2867 DOI: 10.1200/JCO.2009.27.1460
4. Oran B and Weisdorf DJ (2012) Survival for older patients with acute myeloid leukemia: a population-based study Hematologica 97 1916–1924 DOI: 10.3324/haematol.2012.066100
5. Slovak ML, Kopecky KJ and Cassileth PA et al (2000) Karyotypic analysis predicts outcome of preremission and postremission therapy in adult acute myeloid leukemia: a southwest oncology group/eastern cooperative oncology group study Blood 96 4075–4083 PMID: 11110676
6. Wouters BJ, Lowenberg B and Erpelink-Verschueren CA et al (2009) Double CEBPA mutations, but not single CEBPA mutations, define a subgroup of acute myeloid leukemia with a distinctive gene expression profile that is uniquely associated with a favourable outcome Blood 113 3088–3091 DOI: 10.1182/blood-2008-09-179895 PMID: 19171880 PMCID: 2662648
7. Serve H, Krug U and Wagner R et al (2013) Sorafenib in combination with intensive chemotherapy in elderly patients with acute myeloid leukemia: results from randomized, placebo-controlled trial J Clin Oncol 31 3310–3118 DOI: 10.1200/JCO.2012.46.4990
8. Fernandez HF, Sun Z and Yao X et al (2009) Antracycline dose intensification in acute myeloid leukemia N Engl J Med 361 1249–1259 DOI: 10.1056/NEJMoa0904544 PMID: 19776406
9. Burnett AK, Russel NH and Hills RK et al (2012) Addition of gemtuzumab ozogamicin to induction chemotherapy improves survival in older patients with acute myeloid leukemia J Clin Oncol 30 3924–3931 DOI: 10.1200/JCO.2012.42.2964 PMID: 22851554
10. SEER cancer statistics rewiew 1975–2008: MDS, chromic myeloproliferative disorders and CMML Available from http://seer.cancer.gov/csr/1975-2008/result-merged/sect-30-mds.pdf Accessed 2 August 2014
11. Golshayan AR, Jin T and Maciejewski J et al (2007) Efficacy of growth factors compared to other therapies for low-risk MDS Br J Hematol 137 125–132 DOI: 10.1111/j.1365-2141.2007.06546.x
12. List A, Dewald G and Bennet J et al (2006) Lenalidomide in MDS with chromosome 5q deletion N Engl J Med 355 1456–1465 DOI: 10.1056/NEJMoa061292 PMID: 17021321
13. Yang H, Bueso-Ramos C and Dinardo C et al (2014) Expression of PD-L1 PD-L2, PD-1 and CTLA4 in MDS is enhanced by treatment with hypometylating agents Leukemia 28 1280–1288 DOI: 10.1038/leu.2013.355 PMCID: 4032802
14. Horn H, Ziepert M and Becher C et al (2013) MYC status in concert with BCL2 and BCL6 expression predicts outcome in DLBCL Blood 121 2253–2263 DOI: 10.1182/blood-2012-06-435842 PMID: 23335369
15. Johnson NA, Slack GW and Savage KJ et al (2012) Concurrent expression of MYC and BCL2 in DLBCL treated with rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone J Clin Oncol 30 3452–3459 DOI: 10.1200/JCO.2011.41.0985 PMID: 22851565 PMCID: 3454768
16. Dunleavy K, Pittaluga S and Shovlin M et al (2013) Concurrent expression of MYC/BCL2 protein in newly diagnosed DLBCL is not associated with an inferior survival after EPOCH-R therapy Blood (ASH Annual Meeting Abstracts)122 3029
17. Rossi D, Fangazio M and Rasi S et al (2013) Disruption of BIRC3 associates with fludarabine chemorefratoriness in TP53 wild-type chronic lymphocytic leukemia Haematologica 98 675–685
18. Dutia M, De Rook I and Chee K et al R2: preliminary results of phase II study of lenalidomide and rituximab in relapsed/refractory indolent non Hodgkin lymphoma Blood (ASH Annual Meeting Abstracts) 114 1679
19. Armand P, Nagler A and Weller EA et al (2013) Disabling immune tolerance by programmed death-1 blockade with pidilizumab after autologous hematopoietic stem cell transplantation for DLBCL results of an international phase II trial J Clin Oncol 31 4199–4206 DOI: 10.1200/JCO.2012.48.3685 PMID: 24127452
20. Westin JR, Chu F and Zhang M et al (2014) Safety and activity of PD1 blockade by pidilizumab in combination with rituximab in patients with relapsed follicular lymphoma: a single group, open-label, phase 2 trial Lancet Oncol 15 69–77 DOI: 10.1016/S1470-2045(13)70551-5 PMCID: 3922714
21. Novero A, Ravella PM, Chen Y, Dous G and Liu D (2014) Ibrutinib for B cell malignancies Exp Hematol Oncol 3 4 DOI: 10.1186/2162-3619-3-4 PMID: 24472371 PMCID: 3913970
22. Lohr JG, Stojanov P and Carter SL et al (2014) Widespread genetic heterogeneity in multiple myeloma: implications for targeted therapy Cancer Cell 25 91–101 DOI: 10.1016/j.ccr.2013.12.015 PMID: 24434212 PMCID: 4241387
23. Dimopoulos M, Siegel DS and Lonial S et al (2013) Vorinostat or placebo in combination with bortezomib and dexamethasone in patients with relapsed and bortezomin-refractory myeloma Blood 122 2331–2337 DOI: 10.1182/blood-2013-01-481325
