The efficacy and safety of CD52 antibody alemtuzumab to treat severe acute GVHD in 18 consecutive patients refractory to standard high-dose corticosteroid therapy is reported. Patients (age range 13-68 years) had developed acute GVHD grade III and IV with gut and/or liver involvement after stem cell transplantation from family donors (n ¼ 7) or HLA-matched unrelated donors (n ¼ 11), including five donors with one or two HLA mismatches. Initially, in three patients, start doses of alemtuzumab in the range of 70-80 mg were applied and repeated after 3 to 4 weeks. Impressive responses were seen, but virus reactivation and bacterial infections were frequent. In an attempt to reduce this complication, the next nine patients received a reduced starting dose of 20-33 mg, and the last six patients received 3-13 mg repeated every 2-3 weeks. Seventeen of 18 patients responded to alemtuzumab, six patients are alive with a median followup of 108 weeks. Chronic GVHD was observed frequently. Although pronounced lymphocyte depletion requiring close monitoring for signs of infections seems inevitable for efficacy, alemtuzumab given in moderate doses has a substantial activity not only in intestinal but also in severe acute GVHD of the liver.

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In this multicenter study, 30 patients undergoing matched related or unrelated allogeneic stem-cell transplantation for leukemia were treated with palifermin, and retrospectively compared to a matched control group. Palifermin recipients transplanted with an unrelated donor showed a significant reduction of severity, incidence and duration of oral mucositis WHO grades 2-4. In addition, in the palifermin group the use of opioid analgesics and the duration of total parenteral nutrition decreased, whether stem cells were used from matched related or unrelated donors. No beneficial influence of palifermin on the incidence and severity of acute GVHD (aGVHD) was apparent. The incidence and duration of febrile neutropenia, documented infections, hematopoietic recovery or overall survival remained unchanged. The most common adverse effects included rash or erythema, generally mild and transient in appearance. Thus, the administration of palifermin was generally well tolerated and safe, and significantly reduced oral mucositis whereas-regardless of donor status-no effect on the incidence and severity of aGVHD was seen.

Natural killer (NK) cells are crucial effector cells of the innate immune system capable of rapidly recognizing and eliminating infected, stressed and malignant cells. NK cells are also the prime mediators of antibody-dependent cell-mediated cytotoxicity (ADCC), a potent mechanism of anti-viral immunity that has been applied to cancer therapy by targeting tumor-expressed surface antigens using monoclonal antibodies (mAbs). Classical ADCC is mediated by low affinity Fc-mediated engagement of NK cells via FcγRIIIA (CD16A) and is modulated by differences in target antigen expression levels. While high potency of therapeutic mAbs is achieved when target antigen is available at high density, potency and efficacy decrease substantially when copy numbers are low. Classical ADCC also needs to overcome the inhibitory effect of competing serum IgG and is negatively affected by a low affinity polymorphism of CD16A (158F) that is prevalent in approximately 8 of 10 individuals. Hence, classical Fc-mediated ADCC does not fully utilize the therapeutic potential of NK cell cytotoxicity. B cell maturation antigen (BCMA) has emerged as a promising target for treatment of multiple myeloma (MM) due to its near universal expression on tumor cells and restricted expression in non-malignant tissues. Numerous therapeutic approaches are currently investigated clinically and pre-clinically and target BCMA, however, none of these are aimed at fully utilizing NK cell-mediated ADCC. Low copy numbers of BCMA (approx. 40-15,000) might limit the activity of classical mAbs against BCMA, especially in the presence of high serum concentrations of paraprotein. In addition, NK cells may be ideally suited to target minimal residual disease immediately before or after autologous stem cell transplantation. Consequently, by efficiently redirecting NK cell cytotoxicity to BCMA+ myeloma, AFM26 used alone or in combination with other approaches may provide a novel, optimized treatment strategy. Here we describe development of AFM26, a BCMA and CD16A-directed tetravalent bispecific antibody that selectively engages CD16A+ effector cells, including NK cells, and is designed to overcome the limitations of classical ADCC. AFM26 is based on the recently launched Redirected, Optimized Cell Killing (ROCK) antibody platform and combines high affinity CD16A-directed effector cell engagement with IgG-like pharmacokinetics and manufacturability. We demonstrate that AFM26 interacts with NK cells with high avidity independently of CD16A polymorphism and in presence of competing IgG. NK cell-mediated lysis of BCMA+ target cell lines induced by AFM26 is largely independent of BCMA expression levels with high potency and efficacy observed at low copy numbers (<200), as confirmed by autologous lysis of primary MM cells in vitro. Despite more potent and efficacious in vitro lysis, release of inflammatory cytokines is comparable with classical antibody formats. We further demonstrate anti-tumor activity of AFM26 in combination with adoptive transfer of primary human NK cells in vivo using human IL-15-transgenic NOG mice. AFM26 therefore is a promising agent currently in preclinical development to fully unlock NK cell cytotoxicity for BCMA-directed immunotherapy of MM. Disclosures Ross: Affimed: Employment. Reusch:Affimed: Employment. Wingert:Affimed: Employment. Haneke:Affimed: Employment. Klausz:Affimed: Research Funding. Otte:Affimed: Research Funding. Schub:Affimed: Research Funding. Knackmuss:Affimed: Employment. Müller:Affimed: Employment. Ellwanger:Affimed: Employment. Fucek:Affimed: Employment. Schniegler-Mattox:Affimed: Employment. Koch:Affimed GmbH: Employment. Valerius:Affimed: Research Funding. Gramatzki:Affimed: Research Funding. Peipp:Affimed: Research Funding. Tesar:Affimed: Employment. Rajkovic:Affimed: Employment. Treder:Affimed GmbH: Employment.

Patients with relapsed or refractory advanced T cell non-Hodgkin lymphoma have a dismal prognosis and may not even reach allogeneic hematopoietic stem cell transplantation (HSCT) in adequate condition. We present the outcome of 24 consecutive patients (age range 11 to 65 years) treated at a single institution in Kiel within a recent 5.5-year time frame with allogeneic HSCT in a rather uniform approach. Relapsed and refractory T and natural killer cell lymphomas of various subtypes were included. All patients except 1 were in progression or relapse before start of pretransplantation salvage therapy. Five patients had relapsed after autologous HSCT. With intensive remission induction therapy, usually the CLAEG (cladribine, cytosine arabinoside, and etoposide with granulocyte colony-stimulating factor support) protocol, attempts were made to improve disease control and proceed immediately to conditioning with carmustine, etoposide, cytosine arabinoside, melphalan (BEAM), and medium-dose alemtuzumab. Twenty of 21 patients who received CLAEG induction therapy benefited from this protocol and 1 patient appeared to be therapy-resistant. At the time of allogeneic HSCT, 9 patients were in complete remission (CR) (2 in CR1, 5 in CR2, and 2 in CR >2), whereas 50% had never achieved CR. Nineteen transplants were obtained from matched or partially matched unrelated donors and only 5 from siblings. With a median follow-up of 321 days (1252 days for surviving patients), 20 of 22 assessable patients reached CR. Five of these patients had hematologic or molecular relapse. With donor lymphocyte infusions, 1 patient became minimal residual disease MRD negative again and has maintained CR for more than 4 years. The frequency of grades II to IV acute graft-versus-host disease was 25% and chronic graft-versus-host disease, 30%. Intense reinduction therapy followed by reduced-intensity BEAM-alemtuzumab conditioning and allogeneic HSCT is effective and offers curative potential for patients with advanced T cell lymphomas, even for those not in remission.