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PubMed2002

Modulating apoptosis pathways in low-grade B-cell malignancies using biological response modifiers.

Collectively, low-grade B-cell malignancies constitute the fifth most common form of potentially lethal cancer in North America and Europe, with chronic lymphocytic leukemia (CLL) and follicular non-Hodgkin's lymphoma (FL) representing the most prevalent of these disorders. Chronic lymphocytic leukemia and FL represent quintessential examples of human malignancies that are caused primarily by defects in programmed cell death (apoptosis). During the early stages of disease, the mature B lymphocytes that comprise most CLLs and FLs are largely quiescent G(0) phase cells, which accumulate not because they are dividing more rapidly than normal but because they survive longer than their normal counterparts because of defects in the normal pathways for apoptosis. Defects in apoptosis pathways contribute to chemoresistance, rendering tumor cells less sensitive to the cytotoxic actions of currently available anticancer drugs, and can also promote resistance to cellular immune responses. Several biological agents or their synthetic derivatives show promise as apoptosis modulators, having the potential to place neoplastic cells into a more susceptible state or activating latent programs for cell suicide. These biological response modifiers include monoclonal antibodies such as rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) that alter signal transduction pathways, cytokines such as TRAIL (Apo2 ligand), ligands for retinoid/steroid family nuclear receptors, and small-molecule compounds that bind and inhibit protein kinases. Knowledge about the mechanisms by which these agents influence apoptosis pathways in neoplastic diseases may suggest strategies for more effective and less toxic therapies for patients suffering from CLL, FL, and other malignancies.

Animals↗
PubMed2002

Rituximab as first-line and maintenance therapy for patients with indolent non-Hodgkin's lymphoma: interim follow-up of a multicenter phase II trial.

The purpose of this study is to evaluate the activity of rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) in the first-line treatment of patients with indolent non-Hodgkin's lymphoma, and to evaluate the role of scheduled maintenance courses of rituximab in prolonging duration of remission. Sixty-two patients with stages II to IV indolent non-Hodgkin's lymphoma (follicular or small lymphocytic) who had received no previous systemic therapy entered this multicenter, community-based trial. All patients received rituximab 375 mg/m(2) weekly for 4 consecutive weeks, and were evaluated for response at week 6. Patients who had an objective response or stable disease continued treatment every 6 months with repeat 4-week courses of rituximab for a total of four treatment courses. Interim results of this ongoing trial are available. When evaluated at week 6, 28 of 60 evaluable patients (47%) had objective response and 27 patients (45%) had minor response or stable disease. With further follow-up and repeat courses of rituximab, the major response rate increased from 47% to 65% and the complete response rate increased from 7% to 27%. Response rates were similar in patients with follicular lymphoma and small lymphocytic lymphoma (63% and 66%, respectively). Median progression-free survival has not been reached, but will be greater than 24 months. There has been no cumulative toxicity observed with repeat courses of rituximab. Rituximab is highly effective as a first-line single agent for the treatment of indolent non-Hodgkin's lymphoma. The initial response rate can be improved by using scheduled maintenance courses of rituximab administered every 6 months. Final information regarding duration of response and time to progression awaits further follow-up.

Adult↗
PubMed2002

Rituximab in the treatment of diffuse large B-cell lymphomas.

A review of the use of rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) in diffuse large B-cell lymphomas is presented, focusing on the recent presentation of the combination of CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) plus rituximab in elderly patients. This combination increased the response rates, event-free survival, and overall survival of patients older than 60 years in comparison with CHOP alone. The toxic events observed with the combination were not more numerous or severe than those observed with CHOP alone. Rituximab is a chimeric anti-CD20 antibody that increases the treatment options in patients with B-cell lymphomas.

Antibodies, Monoclonal↗
PubMed2002

The role of rituximab and chemotherapy in aggressive B-cell lymphoma: a preliminary report of dose-adjusted EPOCH-R.

Accumulating evidence suggests that the ability to activate apoptotic pathways may be an important determinant of chemotherapy sensitivity and presents a potentially important new therapeutic strategy. Monoclonal antibodies against the CD20 antigen directly induce apoptosis and may serve to modulate the threshold for chemotherapy-induced apoptosis. Rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA), a monoclonal antibody against CD20, was combined with dose-adjusted EPOCH (infusional etoposide/vincristine/doxorubicin/bolus cyclophosphamide/prednisone) chemotherapy and tested in 38 untreated or relapsed poor-prognosis aggressive lymphomas. Twenty-three patients were untreated. Of these patients, all had large B-cell histologies, a median age of 52 years, Eastern Cooperative Oncology Group performance status > or = 2 in 30%, and high-intermediate or high International Prognostic Index scores in 61%. Fifteen patients had relapsed or refractory lymphomas. These patients had received a median of two (range, one to four) prior regimens, 67% had aggressive histologies, and 60% had high-intermediate or high International Prognostic Index scores. Complete remissions were achieved in 85% and 64% of untreated and previously treated patients, respectively; additionally 42% of patients with disease refractory before therapy achieved complete remission. At a median follow-up of 12 months, progression-free and overall survival in the previously untreated group was 85% and 79%, respectively, and no patient in complete remission has relapsed. These results suggest that rituximab may modulate the sensitivity of B-cell lymphomas to chemotherapy.

Adult↗
PubMed2002

Quantitative real-time polymerase chain reaction for monitoring minimal residual disease in patients with advanced indolent lymphomas treated with rituximab, fludarabine, mitoxantrone, and dexamethasone.

Fludarabine and rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) are active against indolent lymphomas. We have previously shown the safety and efficacy of the combination of FND (fludarabine/mitoxantrone/dexamethasone) in relapsed and subsequently untreated patients with stage IV indolent lymphomas. Currently, we treat patients with stage IV indolent lymphomas who are previously untreated, younger than 60 years, human immunodeficiency virus-negative, and have adequate organ and marrow function with FND and random assignment to concurrent or delayed administration of rituximab. We have developed a quantitative real-time polymerase chain reaction assay for t(14;18). With 1 microg of DNA, this assay detects 0.6 copies in 55% of reactions, as expected for the Poisson distribution. When 1microg of DNA was analyzed in duplicate, cells with the t(14;18) were detected in peripheral blood of 22% of 152 volunteer blood donors. Quantitation showed that numbers of t(14;18) cells were higher than the statistical upper normal limit (mean of all volunteer values plus standard deviations) in 2% of volunteer blood donors. By contrast, 36% of blood or marrow specimens from follicular lymphoma patients were positive, and the number of cells with t(14;18) was higher than the normal upper limit in 26%. The presence of cells with t(14;18) and their numbers are prospectively quantitated in blood and marrow of patients treated with FND plus rituximab to determine their clinical significance both at presentation and during therapy.

Actins↗
PubMed2002

Immunotherapy with rituximab following high-dose therapy and autologous stem-cell transplantation for mantle cell lymphoma.

Advanced-stage mantle cell lymphoma (MCL) is a disease for which no curative treatment strategy exists. Results with standard combination chemotherapy, with or without an anthracycline, are disappointing, and new and better therapies are needed. High-dose therapy and autologous stem-cell transplantation (ASCT) have been performed in patients with MCL both up front and at relapse with varying degrees of success. Rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) has shown moderate response rates in patients with MCL. It has also been used safely and effectively as an in vivo purge during ASCT for patients with lymphoma. We are currently investigating an aggressive protocol in patients with newly diagnosed, untreated MCL using a combination of two promising therapeutic modalities, high-dose therapy-ASCT and rituximab. Since 1999, 13 patients with newly diagnosed MCL have been enrolled in this phase II clinical trial. CHOP (cyclophosphamide/prednisone/vincristine/doxorubicin) is used as debulking chemotherapy. Stem cells are mobilized with 5 days of granulocyte colony-stimulating factor 10 microg/kg/d, with a single infusion of rituximab 375 mg/m(2) used as an in vivo purge before stem-cell collection by large-volume leukapheresis. The transplant conditioning regimen is cyclophosphamide/carmustine/etoposide. Post-transplant consolidative immunotherapy consists of rituximab 375 mg/m(2), administered as two 4-week cycles at 2 and 6 months post-transplant. So far, 12 patients (7 men/5 women) with a median age of 55 years (range, 41 to 65 years) have been transplanted. Patients were first assessed and then transplanted a median of 40 and 201 days, respectively, from diagnosis. International Prognostic Index at diagnosis was low (n = 3), low-intermediate (n = 8), and high-intermediate (n = 1). A median of six cycles of CHOP was required to debulk tumor sufficiently for transplant. Response to CHOP was 100% with six complete responses, one complete response unconfirmed, and five partial responses. Transplantation was well tolerated. Patients engrafted quickly, with a median of 11.5 days to neutrophil engraftment and 10 days to platelet independence. Patients had modest transfusion requirements, requiring a median of four units of packed red blood cells and two and a half platelet transfusions. Six to 8 weeks post-transplant, six patients were in complete response, four in complete response unconfirmed, and two in partial response. Eight patients have received all eight maintenance rituximab treatments, and four have received only their first cycle. Following rituximab, the two patients in partial response and two in complete response unconfirmed converted to complete response. With a median follow-up of 239 days from transplant (range, 61 to 727 days), all patients remain alive and well with no documented relapses. Samples for molecular monitoring have been drawn from the stem-cell graft, and serially from the peripheral blood and bone marrow of patients at baseline, preapheresis, pretransplant, and post-transplant at 3-month intervals. This data shows that ASCT followed by rituximab immunotherapy is feasible and safe in patients with MCL. Although patient numbers are low and follow-up time is short, preliminary results are encouraging. Rituximab may convert partial responders to complete responders. The durability of responses will be determined with longer follow-up.

Adult↗
PubMed2002

Emerging information on the use of rituximab in chronic lymphocytic leukemia.

Rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) is a chimeric monoclonal antibody that targets mature B cells in most lymphoid B-cell malignancies. While rituximab was approved by the US Food and Drug Administration for the treatment of recurrent B-cell lymphoma, initial studies suggested that it had less activity in small lymphocytic lymphoma, the nodal counterpart of chronic lymphocytic leukemia (CLL). Two studies have now investigated the activity of higher-dose and more intensive therapy with rituximab in CLL. They have shown a dose-response relationship and a higher response rate than previously seen in the lower-dose studies. This is presumably caused by the overcoming of lower antigen density on CLL cells compared with lymphoma cells, and the shorter half-life of rituximab in small lymphocytic lymphoma. There is now evidence that CD20 is shed into the plasma in patients with CLL, which may explain the shorter half-life of the antibody in small lymphocytic lymphoma/CLL. The higher dose may then be effective in overcoming this so-called "antigen sink." Toxicity was uncommon except in previously untreated patients and those with atypical forms of CLL such as mantle cell lymphoma and prolymphocytic leukemia. There is now evidence in vitro of additive or synergistic activity of rituximab with a variety of chemotherapeutic agents including fludarabine and cyclophosphamide. Combinations of fludarabine with rituximab or these two drugs combined with cyclophosphamide have given very high complete response rates in series of patients with both previously untreated and treated CLL. It is apparent that rituximab is playing a significant role in the management of patients with CLL as salvage therapy and is a potential potentiating agent for combined chemoimmunotherapy strategies for front-line or relapsed patients with CLL.

Antibodies, Monoclonal↗
PubMed2002

Conceptual aspects of combining rituximab and Campath-1H in the treatment of chronic lymphocytic leukemia.

Monoclonal antibody-based therapy has emerged as a novel approach in the treatment of hematologic malignancies. The safety and tolerability of monoclonal antibodies make these compounds attractive and easy to administer, even in elderly, heavily pretreated patients. Chronic lymphocytic leukemia is an incurable disease with few therapeutic options once patients fail purine analogue-based therapy. Two monoclonal antibodies have shown activity in this disease. The first is rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA), a chimeric human-mouse anti-CD20 antibody. The second is Campath-1H, a humanized form of a rat antibody active against CD52. We hypothesize that combining both antibodies in patients who have failed conventional therapies and express both CD20 and CD52 might have enhanced efficacy and therapeutic benefit. This concept is being explored at our institution in the context of a phase I/II clinical trial. The outcome and feasibility of this combination opens the way for future combination therapies using novel biologic agents.

Alemtuzumab↗
PubMed2002

Immunotherapy of non-Hodgkin's lymphoma with hLL2 (epratuzumab, an anti-CD22 monoclonal antibody) and Hu1D10 (apolizumab).

Clinical activity of anti-CD20 monoclonal antibodies both in the unlabeled (rituximab [Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA]) and radiolabeled forms, as well as radioimmunoconjugates targeting other antigens, has resulted in the exploration of alternative targets for immunotherapeutic strategies in lymphoma. We report on the rationale for and initial efforts in the development of two unlabeled, humanized monoclonal antibodies directed against molecules commonly expressed in B-cell malignancies. hLL2 (epratuzumab; Immunomedics, Inc, Morris Plains, NJ) binds to the CD22 antigen, while Hu1D10 (apolizumab; Protein Design Labs, Inc, Fremont, CA) reacts with a polymorphism on the HLA-DR beta chain. Preclinical studies and early clinical evaluations suggest that these agents have a potential role as novel therapeutic targets for lymphoma with acceptable toxicity profiles. Further efforts will explore optimal clinical settings for their use, as well as define treatment regimens either as single agents or in combination with chemotherapy or other biologics.

Antibodies, Monoclonal↗
PubMed2002

Synergism between cytosine-guanine oligodeoxynucleotides and monoclonal antibody in the treatment of lymphoma.

Synthetic oligodeoxynucleotides containing unmethylated cytosine-guanine dinucleotides (CpG ODN) are potent immunostimulatory agents that can activate various immune cell subsets. We have found that CpG ODN show a variety of effects that could be useful in enhancing the efficacy of antibody therapy of lymphoma. In a mouse model, CpG ODN alone had no effect on survival of animals inoculated with lymphoma. In contrast, CpG ODN plus monoclonal antibody (MAb) was more effective at inhibiting tumor growth than MAb alone or MAb plus control ODN. Cytosine-guanine ODN plus MAb cured mice with a large tumor burden that could not be cured with MAb therapy alone. We also evaluated the effects of CpG ODN on the phenotype of human malignant B cells. Cytosine-guanine ODN upregulated the expression of a number of antigens, including CD20. The upregulation of CD20 was most extensive in cells that had low baseline expression of this antigen. We conclude that CpG ODN enhances the efficacy of MAb in a murine lymphoma model, most likely by activating effector cells, and upregulates expression of CD20 on primary human malignant B cells. Given the effects of CpG ODN on both target antigen expression and effector-cell function, further evaluation of the combination of CpG ODN plus rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) and CpG ODN plus other MAbs is warranted.

Adjuvants, Immunologic↗
PubMed2002

Advances in classification and therapy of indolent B-cell malignancies.

Advances in our understanding of normal B-cell differentiation have allowed for improved classification and therapy of B-cell malignancies. B-cell neoplastic diseases may be classified more accurately according to the differentiation stages of presumed normal B-cell counterparts. These advances have challenged the notion that chronic lymphocytic leukemia represents a malignancy of naive CD5 B cells. Analyses of immunoglobulin genes and gene expression patterns through microarray have defined at least two types of chronic lymphocytic leukemia that differ in their tendency toward disease progression. Nevertheless, these types still share more in common than they do with other lymphoid malignancies, and both may be derived from memory-type B cells. Advances in immune therapy are revolutionizing the approach to therapy. B-cell surface differentiation antigens constitute tissue-specific targets for passive immune therapy. Since the US Food and Drug Administration approval of rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) for use in the treatment of follicular lymphoma, monoclonal antibody therapy is being considered for all types of B-cell malignancies. The ability to transform leukemia and lymphoma B cells into effective antigen-presenting cells through CD40 ligation allows for autologous immune recognition of neoplastic cells. Together, active and passive immune approaches have potential for effective treatment of patients with these diseases.

Antibodies, Monoclonal↗
PubMed2002

Rituximab: ongoing and future clinical development.

Monoclonal antibodies have been used as therapeutic agents for many years. In 1997, rituximab (Rituxan; Genentech, Inc, South San Francisco, CA, and IDEC Pharmaceuticals, San Diego, CA) became the first monoclonal antibody to be approved by the US Food and Drug Administration for a cancer indication. The use of rituximab in the treatment of low-grade or follicular, relapsed, or refractory CD20-positive B-cell non-Hodgkin's lymphoma was approved in November 1997 for United States marketing under the trade name Rituxan. In June 1998, rituximab was approved for all European Union countries under the trade name MabThera as therapy for patients with stage III/IV, follicular, chemoresistant, or relapsed (> or = 2 relapses) non-Hodgkin's lymphoma. To date, rituximab has been approved in 56 countries. Over 125,000 patients have been treated with this antibody in the United States alone. Rituximab served to heighten interest in the therapeutic applications of monoclonal antibodies. Literally dozens of antibodies are currently under investigation for a variety of malignant and non-neoplastic indications. The US Food and Drug Administration approved a new (revised) package insert in early 2001. These revisions have been communicated to physicians via a "Dear Doctor Letter" and will appear in the 2002 edition of the Physicians' Desk Reference. A significant amount of clinical research has been performed over the past 9 years, which has served to further our understanding of the potential clinical applications for this novel therapeutic agent. Ongoing and future clinical trials are reviewed in this article. However, much remains to be accomplished in key areas such as combinations with chemotherapy, biologics (including other antibodies), and radiotherapy/radioimmunotherapy; its role within multimodality regimens; and other malignant (beyond low-grade non-Hodgkin's lymphoma) and nonmalignant applications.

Antibodies, Monoclonal↗
PubMed2002

Third generation thrombolytics for the treatment of ischemic stroke.

The field of intravenous and intra-arterial thrombolysis for the treatment of acute ischemic stroke is rapidly advancing. Limitations of existing thrombolytic agents have prompted the development of new thrombolytic agents over the last decade. These new agents are broadly classified as third generation thrombolytics. Two of the several third generation thrombolytic agents have been investigated for the treatment of acute ischemic stroke and include tenecteplase (Genentech Inc) and reteplase (Roche Holding AG). By virtue of structural modifications, third generation thrombolytics have longer half-lives and greater penetration into the thrombus matrix. Tenecteplase has been evaluated in experimental models of ischemic stroke. These experimental studies have observed faster and more complete recanalization of occluded arteries compared with second-generation thrombolytics. The first prospective human clinical trial evaluated the safety and efficacy of intra-arterial reteplase in 16 patients with ischemic stroke who were poor candidates for intravenous alteplase therapy. Near complete or complete recanalization was observed after treatment in 88% of the patients. The development and use of third generation thrombolytics is expected to increase the rate of recanalization and clinical recovery in patients with ischemic stroke. Clinical trials are required to determine the appropriate dose and patient selection for these emerging pharmacological agents.

Animals↗
PubMed2003

Tezosentan. Actelion/Genentech.

Tezosentan is an endothelin receptor antagonist in development by Actelion Ltd and Genentech Inc for the potential treatment of cardiovascular disorders, including acute heart failure (AHF) and congestive heart failure. Actelion has conducted a phase III study of tezosentan in AHF patients, however, following disappointing trial results a new phase III study in AHF was planned using lower doses of the compound. By January 2003, Actelion anticipated that the first results of a two-year phase III study evaluating mortality/morbidity would be available by early 2005.

Animals↗
PubMed2003

Preclinical studies with Erlotinib (Tarceva).

Erlotinib HCl (Tarceva; Genentech, Inc, South San Francisco, CA) is an orally available, highly selective, reversible inhibitor of epidermal growth factor receptor (HER1/EGFR) tyrosine kinase. Inhibition of tyrosine kinase activity prevents HER1/EGFR phosphorylation, the associated downstream signaling events, and may block tumorigenesis mediated by inappropriate HER1/EGFR signaling. In vitro and in vivo studies show that erlotinib has activity against human colorectal, head and neck, non-small cell lung, and pancreatic tumor cells. Recent preclinical studies suggest that erlotinib may also have activity against tumors that are dependent on HER2 activation for growth and/or survival. Preclinical studies have addressed the feasibility of using erlotinib in combination with various chemotherapeutic agents, radiotherapy, and targeted agents. Combining agents that have different mechanisms of action has the potential to improve efficacy and inhibit the development of resistance. For example, in preclinical studies, combining erlotinib with cisplatin, doxorubicin, gemcitabine, or low-dose paclitaxel has an additive effect on antitumor activity with no increase in toxicity. Preclinical data provide a strong rationale for investigating erlotinib in the clinical setting. However, additional studies are required to gain further insights into the processes that regulate or influence the antitumor activity of erlotinib.

Animals↗
PubMed2003

Pharmacokinetics and pharmacodynamics: maximizing the clinical potential of Erlotinib (Tarceva).

Pharmacokinetic and pharmacodynamic studies have an important role in the optimization of targeted agents. Phase I pharmacokinetic studies show that treatment with erlotinib HCl (Tarceva; Genentech Inc, South San Francisco, CA), an orally available epidermal growth factor receptor (HER1/EGFR)-tyrosine kinase inhibitor, on a daily, uninterrupted schedule is feasible. Also, plasma drug concentrations, likely to be clinically effective based on preclinical studies, are consistently achieved at the recommended phase II dose of 150 mg/day, the maximum tolerated dose. Pharmacodynamic studies are in progress to assess the activation of HER1/EGFR and associated downstream signaling pathways in tissue samples from patients treated with erlotinib. Expression of p27 is identified as a potential surrogate marker of erlotinib activity, and is a focus of ongoing and future studies. Also, studies indicate that skin may be a useful surrogate tissue for evaluating the pharmacodynamic effects of therapy. These studies will hopefully enable us to accurately assess the extent of target inhibition in patients treated with erlotinib and help optimize its clinical use.

Antineoplastic Agents↗
PubMed2003

Erlotinib (Tarceva): an update on the clinical trial program.

Erlotinib HCI (Tarceva; Genentech, Inc, South San Francisco, CA) is an orally available, quinazoline-based agent that competes with adenosine triphosphate for binding with the intracellular catalytic domain of epidermal growth factor receptor (HER1/EGFR) tyrosine kinase, inhibiting phosphorylation. This action blocks downstream signal transduction and inhibits the tumorigenic effects associated with ligand-dependent and ligand-independent HER1/EGFR activation. In preclinical studies, erlotinib has substantial antitumor activity against various human tumor xenografts alone and in combination with chemotherapeutic drugs. Phase I data showed that erlotinib was well tolerated, with encouraging antitumor activity in patients with various types of solid tumors. Furthermore, phase II monotherapy trials in patients with advanced non-small cell lung cancer, ovarian cancer, and head and neck squamous cell cancer, respectively, show favorable activity compared with single-agent chemotherapy in similar patient populations. Phase III trials with erlotinib in non-small cell lung cancer and pancreatic cancer are in progress, as are a range of studies in various indications designed to optimize the use of erlotinib alone and in combination with chemotherapy, radiotherapy, and other targeted agents.

Antineoplastic Agents↗
PubMed1992

Clinical experience with tissue plasminogen activator stored at -20 degrees C.

We developed a new dilution technique that allows tissue plasminogen activator (t-PA) to be stored at -20 degrees C, as opposed to the -70 degrees C recommended by the United States manufacturer (Genentech Inc). Following tests that showed neither loss in activity nor microbiological contamination, we clinically proved the efficacy of t-PA stored at -20 degrees C in 10 cases.

Cryopreservation↗