CRIOGLOBULINEMIA MISTA E LINFOMI NELL ERA DEI DAAs DI II GENERAZIONE. Anna Linda Zignego

CRIOGLOBULINEMIA MISTA E LINFOMI NELL ERA DEI DAAs DI II GENERAZIONE Anna Linda Zignego

Eur J Gastroenterol Hepatol, 2017

MC: in the setting of HCV-related pathologies, a typically female disease

Direct medical costs of extrahepatic manifestations of HCV in USA Younossi et al Evaluation of the annual costs (inpatient, outpatient, and pharmacy) associated with extrahepatic manifestations of HCV Total direct medical costs of extrahepatic manifestations of HCV in 2014 US dollars, were estimated to be $1506 million (range, $922 million $2208 million in sensitivity analysis) These estimates should be added to the liverrelated burden of disease to obtain a more accurate assessment of the total burden of HCV infection

Direct medical costs of extrahepatic manifestations of HCV in EUROPE

ISG-EHCV Ferri C, Ramos-Casals M, Zignego AL, et al, Autoimmun Rev 2016

1465 252 496 717 These results, for the first time showed the real-life variability of the MC diagnostic approach, suggesting that MC prevalence in HCV+ is generally underestimated Total Piter cohort no. 8005 subjects: the presence of MC was never tested in 80% of cases in spite of its clinical and therapeutical importance. Among the centres that considered MC= -64% evaluated cryoglobulinemia only following a clinical suspicion -58% evaluated routinely cryoglobulinemia at admission with Complement / RF levels -42% only in case of RF positivity -Cryo testing was not adequate in 39% of centres Kondili et al, Liver Intern.2017

CLASSIFICATION OF HCV EHDS ACCORDING TO THE STRENGTH OF SPECIFIC DATA SUPPORTING THE CURATIVE EFFECT OF AVT Mixed Cryoglobulinemia* Effectiveness of both IFN-based and IFNfree AVT Marginal Zone NHL Effectiveness of both IFN- and DAA-based AVT Other low-grade B-cell NHL // HRQOL High-grade NHL= DLBCL CKD Neuropsychiatric disorders Curaneous= PCT and LP (OLP) Endocrinologic: Thyroid and DM 2 Available data also in DAA-based AVT Insufficient, but positive data Sufficient specific data only for MC-CKD* Problematic IFN-based AVT; Insufficient data with DAAs Problematic IFN/RBV-based AVT; Insufficient data with DAAs Insufficient specific data with DAAs Zignego et al. 2017

Antiviral Treatment (AVT) of MC in the IFN Era AVT of MC followed the evolution of hepatitis C AVT with frequent adjustments essentially due to the possible side-effects of IFN and/or RBV therapy (i.e. IFN neurotoxicity and myelo-inhibitory action and RBV hemolytic effects) Virological and clinical results progressively improved in spite of frequent side-effects Clinical remission was generally correlated with virological response IFN-based AVT was recommended as the first-line option in mild to moderate MC Long follow-up showed that the majority (57%) of SVR pts cleared all MC stigmata Landau DA, et al. Arthritis Rheum 2008; Montalbano M, et al. J Clin Gastroenterol 2007; Cacoub P, et al. Arthritis Rheum 2002; Mazzaro C, et al..j Rheumatol 2003; Zignego AL, et al Hepatology 2016; Gragnani L, et al. Hepatology 2015; Pietrogrande M, et al. Autoimmun Rev 2011.

Antiviral Treatment (AVT) of MC: IFN-free regimens Limited data, so-far concordant, are available regarding IFN-free AVT in MC patients Available data suggest that IFN-free AVT is safe, generally well tolerated and effective in MC patients: high rate of clinical response (87%) and low rates of serious adverse events was reported Zignego AL, Ramos-Casals M, Ferri C et al, Autoimmun.Reviews 2017

Antiviral Treatment (AVT) of MC: IFN-free regimens Lauletta et al, 2017 22 MCS treated with DAAs, including 2 HCC and 2 NHL. 100% SVR12. Clinical R in 100% (64% CR and 36% PR). Progression of the small lymphocytic lymphoma. Emery CS et al, 2017 Retrospective analysis: 17 MCS (10 with severe/life-threatening vasculitis) and 65 asymptomatic MC treated with DAAs. SVR: 88.9% MCS and 90.8% asymptomatic pts. In MCS clinical R in 11/17 (CR in 7/11) Lower clinical R in severe/life-threatening especial renal and neurological- vasculitis Saadoun D et al, 2017 Open-label, prospective, multi-center study on sofosbuvir plus daclatasvir treatment of 41 HCV MCS. SVR in 100% and clinical CR in 90.2% Disappearance of CGs in 50% of pts. No serious adverse event or relapse of vasculitis. Fumiaki et al, 2017 A case of rapid amelioration of HCV-associated cryoglobulinemic MPGN treated by IFN-free DAAs for HCV in the absence of immunosuppressant

Zignego et al. 2017

Gragnani et al. AASLD 2017 Evaluation of The Impact on HRQol of IFN-free AVT In HCV CM TIME POINTS baseline, EOT and week 12 and 24 of post-treatment f-up (SVR12 and SVR24 respectively) HRQoL EVALUATION THROUGH PROs the Short Form (36) Health Survey (SF-36); the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) from which we computed the Trial Outcome Index (TOI) **=p<0.01 vs baseline scores; =p<0.01 and =p<0.001 vs EOT scores 1. Physical Component Summary Score (PCS) A HCV (43) B MC (54) C CV (85) * ** ** * 2. Mental Component Summary Score (MCS) HCV D HCV E MC F CV ** ***

MCS Therapy in the IFN and DAAs Era: from the complex to the simplified flow-chart HCV Eradication with DAAs To be preceded or combined with non-etiological, pathogenetic therapy in severe/catastrophic MCS Dammacco F, Sansonno D, NEJM 2013 Zignego AL, Pawlotsky JM, Cacoub P, Antiviral Ther, in press; Cacoub P et al, Am J Med 2015

Mechanisms of HCV-related lymphomagenesis DLBC: HCV- induced direct transformation? MC/indolent NHL: accumulation of B RF following BCR activation and BC apoptosis inhibition? Zignego AL, Ramos-Casals M, Ferri C et al, Autoimmun. Rev. 2017; Wang et al. Hepatology. 2016; Canioni et al, Plos one. 2016

NS3 immunostaining positive in 12/14 DLBCL vs only 4/14 MZL (p = 0.006); moreover, 2/4 NS3+ MZL were enriched in large cells This study supports a new mechanism of transformation with a direct oncogenic role of HCV proteins in the occurrence of high-grade B lymphomas IN SITU HEPATITIS C NS3 PROTEIN DETECTION IS ASSOCIATED WITH HIGH GRADE FEATURES IN HCV-ASSOCIATED B-CELL NON-HODGKIN LYMPHOMAS. Danielle Canioni et al 2016 In addition to the role of chronic antigenic stimulation in HCV related lymphomagenesis, this study supports a second mechanism of transformation due to a direct oncogenic role of HCV infection of B-cells promoting the occurrence of highgrade Bcell lymphomas Observational study on in situ expression of the oncogenic HCV NS3 protein on 116 HCV patients with B-NHL (DLBCL 36% and MZL 34%)

Cohort study of 704 consecutive HIV-negative, HCV-positive patients with indolent NHL from 1993 to 2009 in 39 centers of the FIL

Arcaini et al. 2016

THERAPY OF HCV+ DLBCL DLBC: HCV- induced direct transformation? No place of AVT as 1st line! Need of immediate delivery of chemotherapy or concomitant (NHL + HCV targets)!

ANTIVIRAL THERAPY IS ASSOCIATED WITH A BETTER SURVIVAL IN PATIENTS WITH HCV AND B-CELL NON- HODGKIN LYMPHOMAS, ANRS HC-13 LYMPHO-C STUDY Michot JM et al Outcomes of HCV-associated B-NHL according to HCV AVT in prospective patients only (n 5 64)

Concurrent Systemic Chemoimmunotherapy and Sofosbuvir-Based Antiviral Treatment in a Hepatitis C Virus-Infected Patient With Diffuse Large B-Cell Lymphoma Evan C. Ewers et al, 2016 absolute neutrophil count and Hgb ALT and HCV viral load Both complete response and SVR of HCV-associated DLBCL, after concurrent chemoimmunotherapy and antiviral therapy using a sofosbuvir-based regimen

DAA-treatment in concomitance with chemotherapy showed to be safe and effective in influencing the remission of aggressive lymphomas in HCV patients Persico M et al, 2017 Antiviral response rates in DAA treated patients DFS in DAA treated and historical, not-treated pts

ANTIVIRAL THERAPY IN HCV+ B CELL NHL IFN-based AVT induced hematological response along with SVR in patients with HCV-related indolent NHLs (especially MZL) Recent data with IFN-free regimens in HCV-associated LPDs suggest their anti-lymphoma activity too AVT should be considered the first-line approach in HCV low grade lymphomas if there is no urgency of a conventional treatment (i.e., systemic symptoms, bulky disease or symptomatic splenomegaly) (ESMO, NCCN,EASL guidelines) In aggressive lymphomas antiviral therapy after induction treatment is to be considered the standard at the moment, but in the next years (months), the association of immunochemotherapy and antiviral therapy will be considered the standard! Zignego AL, Ramos-Casals M, Ferri C et al, Autoimmun. Rev. 2017

The Masve group BASIC RESEARCH Laura Gragnani Patrizio Caini Serena Lorini Antonella Simone Università degli Studi di Firenze Dipartimento di Medicina Sperimentale e Clinica Centro Manifestazioni Sistemiche da Virus Epatitici MASVE Anna Linda Zignego MASVE CLINICAL RESEARCH Monica Monti Luisa Petraccia Sinan Sadalla Guia Cerretelli Cristina Stasi Adela Xheka UNDERGRADUATE STUDENTS: Andrea Genovese, Adrian Piscopo

Main drugs for HCV-related MCS according to the target HCV= DAAs B-cell Expansion= (a) B cell-depleting Mabs -First-generation: Rituximab (anti-cd20) -Second-generation: Ofatumumab (anti-cd20); Veltuzumab (humanized anti-cd20) -Third-generation: Obinutuzumab (GA101); Oceratuzumab (humanized anti-cd20) Inflammation= (b) Alkylating agents -Cyclophosfamide Antiinflammatory agents Altered regulatory T-cell activity= - Corticosteroids - IL-2

The impact on HRQoL of IFN-free AVT was prospectively evaluated in a cohort of HCV CV patients with limited influencing variables linked to therapeutic schedules/viral GT: 44 HCV GT2 CV patients, mostly F0-F2 (29) and naïve (30), treated with SOF/RBV for 12/24wks. TIME POINTS baseline, EOT and week 12 and 24 of post-treatment f-up (SVR12 and SVR24 respectively) HRQoL EVALUATION THROUGH PROs the Short Form (36) Health Survey (SF-36); the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) from which we computed the Trial Outcome Index (TOI)

IN SITU HEPATITIS C NS3 PROTEIN DETECTION IS ASSOCIATED WITH HIGH GRADE FEATURES IN HCV-ASSOCIATED B-CELL NON-HODGKIN LYMPHOMAS. Danielle Canioni et al 2016 In addition to the role of chronic antigenic stimulation in HCV related lymphomagenesis, this study supports a second mechanism of transformation due to a direct oncogenic role of HCV infection of B-cells promoting the occurrence of highgrade Bcell lymphomas Observational study on in situ expression of the oncogenic HCV NS3 protein on 116 HCV patients with B-NHL (DLBCL 36% and MZL 34%) NS3 immunostaining positive in 12/14 DLBCL vs only 4/14 MZL (p = 0.006); moreover, 2/4 NS3+ MZL were enriched in large cells This study supports a new mechanism of transformation with a direct oncogenic role of HCV proteins in the occurrence of high-grade B lymphomas

Concurrent Systemic Chemoimmunotherapy and Sofosbuvir-Based Antiviral Treatment in a Hepatitis C Virus-Infected Patient With Diffuse Large B-Cell Lymphoma Evan C. Ewers et al, 2016 (A) absolute neutrophil count and Hgb (B) ALT and HCV viral load This patient had HCV-associated DLBCL, achieving both complete response and SVR after concurrent chemoimmunotherapy and antiviral therapy using a sofosbuvir-based regimen.

Cumulative Mortality (%) Extrahepatic Manifestations of HCV HCV-EHDs are responsible for increasing morbidity and mortality, with important consequences in terms of social costs The analysis of mortality rates in large cohorts confirmed the association of HCV with several EHDs including cardiovascular, neurologic, metabolic or renal diseases and tumors Viral eradication significantly reduced the rate of extra-hepatic deaths 35 30 25 20 15 10 5 Anti-HCV+, HCV RNA detectable Anti-HCV+, HCV RNA undetectable Anti-HCV All Causes (n=2394) Follow-Up (Years) 30.1%* 12.8% 12.4% 0 0 2 4 6 8 10 12 14 16 18 20 12 10 8 6 4 2 Liver Cancer (n=115) 0.3% 0 0 2 4 6 8 10 12 14 16 18 20 Follow-Up (Years) 10.4%* (Years) Con il contributo di Cacoub P, et al. DLD 2014; Lee MH, et al J Infect Dis 2012; Backus LI, et al. Clin Gastroenterol Hepatol 2011; El-Kamary S, et al. Clin Infect Dis 2011; Hsu YC, et al. Hepatology 2014; Kawamura Y, et al. Am J Med 2007; Adinolfi LE, et al. WJG 2014 1.6% Lee M-H, et al. J Infect Dis. 2012;206:469-477. 20 18 16 14 12 10 8 6 4 2 Extrahepatic Diseases (n=2199) 0 0 2 4 6 8 10 12 14 16 18 20 Follow-Up 19.8%* 12.2% 11.0%

MC is clinically benign, but sometimes severe HCV EHD; invalidating symptoms occur and it may evolve into lymphoma Mixed Cryoglobulinemia-MC CGs reversibly precipitate when the temperature is lower than 37 C and comprise IgMs with RF activity [mono- or oligo-clonal in type II MC, or polyclonal in type III MC] and polyclonal IgGs MC pathological substrate is an HCV-driven B-cell proliferation with consequent production of cryo- and noncryoprecipitable CICs, in turn responsible for vasculitic manifestations Most (70 90%) MC patients are HCV+ and HCV-patients are CGs+ (40 60%), while 5 30% of CGs+ have symptomatic MC: since HCV infects about 170 million individuals worldwide, the number of patients at risk for developing MC is substantial Type II CGs Type III CGs Cacoub P, et al. DLD 2014; Zignego AL, et al. DLD 2007; Zignego AL, et al. Intern Emerg Med 2012; Zignego AL, et al. Clin Dev Immunol 2012; Zignego AL, et al. Expert Rev Clin Immunol 2015; Sene D, et al. J Rheumatol 2004.

MC clinical aspects: MC Syndrome MCS is characterized by the clinical triad -purpura, weakness, and arthralgias-, low complement C4 and various organ/system involvement, including cutaneous, articular, renal, neurological, cardiac or digestive It ranges from mild disease to severe, even life-threatening conditions More serious lesions are generally characterized by neurologic and renal involvement Prognosis is highly dependent on renal involvement or on the extent of vasculitis lesions Zignego AL et al, Autoimmun Rev, 2017; Ferri C et al, Autoimmunity rev. 2016; Zignego AL, et al. DLD 2007; Cacoub P, et al. DLD 2014; Zignego AL, et al. DLD 2007; Zignego AL, et al. Intern Emerg Med 2012; Zignego AL, et al. Clin Dev Immunol 2012; Zignego AL, et al. Expert Rev Clin Immunol 2015.

1: HCV is the From main P etiopathological Cacoub, 2015 agent as concordantly demonstrated by epidemiological, clinico-pathological, virological, and laboratory investigations 2: the association between HCV and disease is demonstrated in a significant proportion of patients and supported by in depth clinico-pathogenetic studies; 3: the association is suggested by cohort studies; a possible causative role may be limited to a small number of patients and/or possibly more relevant in specific geographical areas; 4: a number of anecdotal observations suggested a possible role of HCV; further investigations are required

HCV and MC HCV and MC HCV infection is closely related to LPDs, mostly MC 40 to 60% of HCV patients show circulating CGs; among this latter population, 5-30% develop a symptomatic CV AVT has been considered the first-line option in HCV-CV patients; in fact, in the majority of cases, viral eradication leads to CV clinical remission Data about IFN-free regimens for the treatment of CV patients are still limited Zignego, 2015;Ferri, 2016;Pozzato, 2016; Sise, 2016;Saadoun, 2015;Gragnani, 2016;Gragnani, 2016; Bonacci, 2016;Hegazy, 2016;Kondili 2016;Emery, 2017.

Younossi et al The annual costs (inpatient, outpatient, and pharmacy) associated with extrahepatic manifestations of HCV were evaluated Total direct medical costs of extrahepatic manifestations of HCV in 2014 US dollars, were estimated to be $1506 million (range, $922 million $2208 million in sensitivity analysis) These estimates should be added to the liver-related burden of disease to obtain a more accurate assessment of the total burden of HCV infection

The OBJECTIVE of the study was to estimate the annual direct medical costs associated with HCV related EHM in the EU5 (France, Germany, Italy, United Kingdom, Spain)

Extrahepatic Manifestations of HCV

Extrahepatic Manifestations of HCV HCV may cause extrahepatic disorders (HCV-EHDs), classified according to the number and strength of supporting scientific data

Cumulative Mortality (%) HCV-EHDs are responsible for increasing morbidity and mortality, with important consequences in terms of social costs The analysis of mortality rates in large cohorts confirmed the association of HCV with several EHDs including cardiovascular, neurologic, metabolic or renal diseases and tumors Viral eradication significantly reduced the rate of extra-hepatic deaths 35 30 25 20 15 10 5 Anti-HCV+, HCV RNA detectable Anti-HCV+, HCV RNA undetectable Anti-HCV All Causes (n=2394) 0 0 2 4 6 8 10 12 14 16 18 20 Extrahepatic Manifestations of HCV Follow-Up (Years) 30.1%* 12.8% 12.4% 12 10 8 6 4 2 Liver Cancer (n=115) 0.3% 0 0 2 4 6 8 10 12 14 16 18 20 Follow-Up (Years) 10.4%* (Years) Con il contributo di Cacoub P, et al. DLD 2014; Lee MH, et al J Infect Dis 2012; Backus LI, et al. Clin Gastroenterol Hepatol 2011; El-Kamary S, et al. Clin Infect Dis 2011; Hsu YC, et al. Hepatology 2014; Kawamura Y, et al. Am J Med 2007; Adinolfi LE, et al. WJG 2014 1.6% Lee M-H, et al. J Infect Dis. 2012;206:469-477. 20 18 16 14 12 10 8 6 4 2 Extrahepatic Diseases (n=2199) 0 0 2 4 6 8 10 12 14 16 18 20 Follow-Up 19.8%* 12.2% 11.0%

Younossi et al Costs up to $71,000 per patient per year (ESRD) Among the most frequent EHM, depression (24.5% in HCV vs 17.2 % in non-hcv) had estimated annual cost of $430.7 million DM (15% vs 10% in non- HCV) had an annual cost of $443.4 million in the USA= given the importance of DM and its association with CVDs and mortality, the clinical and economic impacts of HCV-related DM are substantial

The OBJECTIVE of the study was to estimate the annual direct medical costs associated with HCV related EHM in the EU5 (France, Germany, Italy, United Kingdom, Spain)

The most studied and frequent HCV-EHDs are B-LPDs and/or autoimmune disorders 1: HCV is the main etiopathological agent as concordantly demonstrated by epidemiological, clinico-pathological, virological, and laboratory investigations 2: the association between HCV and disease is demonstrated in a significant proportion of patients and supported by in depth clinico-pathogenetic studies; 3: the association is suggested by cohort studies; a possible causative role may be limited to a small number of patients and/or possibly more relevant in specific geographical areas; 4: a number of anecdotal observations suggested a possible role of HCV; further investigations are required Their prototype is Mixed Cryoglobulinemia (MC): from researches on MC derived most of the available information: MC as a precious model for all the HCV-EHDs and to evaluate the effects of viral eradication.

Few side effects, absence major contraindications 100 80 60 40 Standard interferon 1991 Anti-HCV Treatment Evolution Ribavirin 1998 34 42 Peginterferon 2001 39 55 Direct-acting antivirals 2015 2011 70+ >90 20 16 6 0 IFN 6 mos IFN 12 mos IFN/RBV 6 mos IFN/RBV 12 mos PegIFN 12 mos PegIFN/ RBV 12 mos PegIFN/ RBV/ DAA DAAs 8/26 weeks

The OBJECTIVE of the study was to estimate the annual direct medical costs associated with HCV related EHM in the EU5 (France, Germany, Italy, United Kingdom, Spain)

Antiviral Treatment (AVT) of MC: IFN-free regimens Lauletta et al, 2017 22 MCS treated with DAAs, including 2 HCC and 2 NHL. 100% SVR12. Clinical CR in 64% and PR in remaining 36%. The small lymphocytic lymphoma progressed despite viral clearance. Saadoun D et al, 2017 Open-label, prospective, multi-center study on sofosbuvir plus daclatasvir treatment of 41 HCV MCS. SVR in 100% and clinical CR in 90.2% Disappearance of CGs in 50% of pts. No serious adverse event or relapse of vasculitis. Emery CS et al, 2017 Retrospective analysis: 17 MCS (10 with severe/life-threatening vasculitis) and 65 asymptomatic CGs+ pts treated with DAAs. SVR: 88.9% MCS and 90.8% asymptomatic pts. In MCS clinical response in 11/17 (complete in 7/17) In severe/life-threatening vasculitis, lower clinical response, especially in renal and neurological symptoms

Mixed Cryoglobulinemia-MC MC is clinically benign, but sometimes severe HCV EHD; invalidating symptoms occur and it may evolve into lymphoma MC pathological substrate is an HCV-driven B-cell proliferation with consequent production of cryo- and noncryoprecipitable CICs, in turn responsible for vasculitic manifestations Type II CGs: monoclonal RF+policlonal IgG Type III CGs: both RF and IgG polyclonal Most (70 90%) MC patients are HCV+ and HCV-patients are CGs+ (40 60%), while 5 30% of CGs+ have symptomatic MC or cryoglobulinemic vasculitis: since HCV infects about 170 million individuals worldwide, the number of patients at risk for developing MC is substantial Cacoub P, et al. DLD 2014; Zignego AL, et al. DLD 2007; Zignego AL, et al. Intern Emerg Med 2012; Zignego AL, et al. Clin Dev Immunol 2012; Zignego AL, et al. Expert Rev Clin Immunol 2015; Sene D, et al. J Rheumatol 2004.