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Guinan K, Mathurin K, Lachaine J, Roc NP, Bull SJ, Tankala D, Barakat S, Manzoor BS, Hillis C, Banerji V. The Economic Impact of Treatment Sequencing in Chronic Lymphocytic Leukemia in Canada Using Venetoclax plus Obinutuzumab. Cancers (Basel) 2024; 16:3182. [PMID: 39335154 PMCID: PMC11430142 DOI: 10.3390/cancers16183182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Revised: 09/12/2024] [Accepted: 09/13/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Bruton tyrosine kinase inhibitors (BTKis) represent an advancement in chronic lymphocytic leukemia; however, these agents are administered continuously until disease progression or unacceptable toxicity, raising concerns about their affordability. Venetoclax in combination with obinutuzumab (VO) is a fixed-duration (12-month) treatment, approved in Canada in 2020. This study estimated the total cumulative cost of different treatment sequences and evaluated the economic impact of introducing treatment sequences with/without VO, from a Canadian health care system perspective. METHODS A 10-year partitioned survival model was developed, considering key clinical parameters and direct medical costs. Results were stratified by TP53 aberration. RESULTS Treatment sequences starting with first-line (1L) VO resulted in lower 10-year cumulative costs compared to sequences starting with BTKis administered until disease progression, across both TP53 aberration subgroups. With a maximum of three lines of treatment over a 10-year period, cumulative costs were largely determined by the first two lines of treatment. When comparing sequences with the same 1L treatment, sequences with BTKis in second-line incurred greater costs compared to fixed-duration regimens. CONCLUSIONS Overall, the economic impact of treating all patients with VO led to 10-year cumulative savings of CAD 169,341 and CAD 293,731 per patient, without and with TP53 aberration, respectively. These savings are mainly due to reductions in treatment costs associated with fixed treatment duration.
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Affiliation(s)
- Kimberly Guinan
- PeriPharm Inc., Montreal, QC H2Y 2H4, Canada; (K.G.); (K.M.)
| | - Karine Mathurin
- PeriPharm Inc., Montreal, QC H2Y 2H4, Canada; (K.G.); (K.M.)
| | - Jean Lachaine
- PeriPharm Inc., Montreal, QC H2Y 2H4, Canada; (K.G.); (K.M.)
- Faculty of Pharmacy, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Nancy Paul Roc
- AbbVie Corporation, Saint-Laurent, QC H4S 1Z1, Canada; (N.P.R.); (S.-J.B.); (D.T.); (S.B.)
| | - Sarah-Jane Bull
- AbbVie Corporation, Saint-Laurent, QC H4S 1Z1, Canada; (N.P.R.); (S.-J.B.); (D.T.); (S.B.)
| | - Dipti Tankala
- AbbVie Corporation, Saint-Laurent, QC H4S 1Z1, Canada; (N.P.R.); (S.-J.B.); (D.T.); (S.B.)
| | - Stephane Barakat
- AbbVie Corporation, Saint-Laurent, QC H4S 1Z1, Canada; (N.P.R.); (S.-J.B.); (D.T.); (S.B.)
| | | | - Christopher Hillis
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8, Canada;
| | - Versha Banerji
- CancerCare Manitoba Research Institute, Winnipeg, MB R3E 0V9, Canada;
- Departments of Internal Medicine and Biochemistry & Medical Genetics, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
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2
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Huang IJ, Baek GT, Siu C, Shadman M. Pharmacological management of chronic lymphocytic leukemia: current and emerging therapies. Expert Opin Pharmacother 2024; 25:1759-1783. [PMID: 39211945 DOI: 10.1080/14656566.2024.2398603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL), characterized by its monoclonal lymphoproliferative nature, is an indolent but incurable malignancy. The treatment landscape of CLL/SLL has drastically transformed in the last decade since the introduction of targeted therapy and immune-effector T-cell therapy. The paradigm shift from chemoimmunotherapy to targeted and cellular therapies was largely driven by improved efficacy and safety. With the success of targeted therapies, novel agents and combinations are rapidly emerging on the horizon. AREAS COVERED In this review, we will summarize clinical evidence supporting current and emerging therapies with emphasis on investigational therapies and novel combinations of commercial agents. Clinical trials were identified via clinicaltrials.gov, and a PubMed literature search was last performed in June 2024. EXPERT OPINION With the availability of more effective and better-tolerated treatments for CLL/SLL, the role of early intervention should be further investigated due to its potential to alter disease course, delay progression, and improve overall survival rates. With many highly effective agents and combinations expected to become commercially available, attention to safety profiles and careful selection of patients for each treatment will be critical, with consideration of comorbidities, logistical issues, and financial burden of treatment.
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Affiliation(s)
- Ivan J Huang
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Grace T Baek
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Chloe Siu
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mazyar Shadman
- Department of Medicine, Division of Hematology and Medical Oncology Division, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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3
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Rios-Olais FA, McGary AK, Tsang M, Almader-Douglas D, Leis JF, Buras MR, Hilal T. Measurable Residual Disease and Clinical Outcomes in Chronic Lymphocytic Leukemia: A Systematic Review and Meta-Analysis. JAMA Oncol 2024; 10:1221-1227. [PMID: 38990562 PMCID: PMC11240229 DOI: 10.1001/jamaoncol.2024.2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 07/12/2024]
Abstract
Importance Measurable residual disease (MRD) refers to the presence of disease at low levels not detected by conventional pathologic analysis. The association of MRD status as a surrogate end point of clinical outcome in chronic lymphocytic leukemia (CLL) has not been established in the era of targeted agents. Assessing the association of MRD with progression-free survival (PFS) may improve its role as a surrogate marker and allow its use to accelerate drug development. Objective To assess the association between MRD and PFS in CLL using data from prospective clinical trials that studied targeted agents or obinutuzumab-based treatment. Data Sources Clinical studies on CLL were identified via searches of PubMed, Embase, Scopus, and Web of Science from inception through July 31, 2023. Study Selection Prospective, single-arm, and randomized clinical trials that assessed targeted agents or obinutuzumab-based treatment and reported PFS by MRD status were included. Studies with insufficient description of MRD information were excluded. Data Extraction and Synthesis Study sample size, median patient age, median follow-up time, line of treatment, MRD detection method and time points, and survival outcomes were extracted. Main Outcomes and Measures Analyses of survival probabilities and hazard ratios (HRs) were conducted for PFS according to MRD status. Meta-analyses were performed using a random-effects model. Results A total of 11 prospective clinical trials (9 randomized and 2 nonrandomized) including 2765 patients were analyzed. Achieving undetectable MRD (uMRD) at 0.01% was associated with an HR of 0.28 (95% CI, 0.20-0.39; P < .001) for PFS. Median PFS was not reached in both groups (uMRD vs MRD), but the estimated 24-month PFS was better in the uMRD group (91.9% [95% CI, 88.8%-95.2%] vs 75.3% [95% CI, 64.7%-87.6%]; P < .001). The association of uMRD with PFS was observed in subgroup analyses in the first-line treatment setting (HR, 0.24; 95% CI, 0.18-0.33), relapsed or refractory disease setting (HR, 0.34; 95% CI, 0.16-0.71), and trials using time-limited therapy (HR, 0.28; 95% CI, 0.19-0.40). Conclusions and Relevance The findings of this systematic review and meta-analysis suggest that assessing MRD status as an end point in clinical trials and as a surrogate of PFS may improve trial efficiency and potentially allow for accelerated drug registration.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Neoplasm, Residual
- Progression-Free Survival
- Treatment Outcome
- Antibodies, Monoclonal, Humanized/therapeutic use
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Affiliation(s)
- Fausto Alfredo Rios-Olais
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alyssa K. McGary
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, Arizona
| | - Mazie Tsang
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Jose F. Leis
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | - Matthew R. Buras
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Talal Hilal
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
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4
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Lewis RI, Vom Stein AF, Hallek M. Targeting the tumor microenvironment for treating double-refractory chronic lymphocytic leukemia. Blood 2024; 144:601-614. [PMID: 38776510 DOI: 10.1182/blood.2023022861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/08/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
ABSTRACT The introduction of BTK inhibitors and BCL2 antagonists to the treatment of chronic lymphocytic leukemia (CLL) has revolutionized therapy and improved patient outcomes. These agents have replaced chemoimmunotherapy as standard of care. Despite this progress, a new group of patients is currently emerging, which has become refractory or intolerant to both classes of agents, creating an unmet medical need. Here, we propose that the targeted modulation of the tumor microenvironment provides new therapeutic options for this group of double-refractory patients. Furthermore, we outline a sequential strategy for tumor microenvironment-directed combination therapies in CLL that can be tested in clinical protocols.
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Affiliation(s)
- Richard I Lewis
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Alexander F Vom Stein
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
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5
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Tettamanti FA, Kimko H, Sharma S, Di Veroli G. Predicting progression-free survival from measurable residual disease in chronic lymphocytic leukemia. Clin Transl Sci 2024; 17:e13905. [PMID: 39164859 PMCID: PMC11335580 DOI: 10.1111/cts.13905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/31/2024] [Accepted: 07/12/2024] [Indexed: 08/22/2024] Open
Abstract
Association between measurable residual disease (MRD) and survival outcomes in chronic lymphocytic leukemia (CLL) has often been reported. However, limited quantitative analyses over large datasets have been undertaken to establish the predictive power of MRD. Here, we provide a comprehensive assessment of published MRD data to explore the utility of MRD in the prediction of progression-free survival (PFS). We undertook two independent analyses, which leveraged available published data to address two complimentary questions. In the first, data from eight clinical trials was modeled via a meta-regression approach, showing that median PFS can be predicted from undetectable MRD rates at 3-6 months of post-treatment. The resulting model can be used to predict the probability of technical success of a planned clinical trial in chemotherapy. In the second, we investigated the evidence for predicting PFS from competing MRD metrics, for example baseline value and instantaneous MRD value, via a joint modeling approach. Using data from four small studies, we found strong evidence that including MRD metrics in joint models improves predictions of PFS compared with not including them. This analysis suggests that incorporating MRD is likely to better inform individual progression predictions. It is therefore proposed that systematic MRD collection should be accompanied by modeling to generate algorithms that inform patients' progression.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Neoplasm, Residual
- Progression-Free Survival
- Clinical Trials as Topic
- Prognosis
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Affiliation(s)
- Florencia A. Tettamanti
- Clinical Pharmacology and Quantitative Pharmacology, CPSS, BioPharmaceuticals R&DAstraZenecaCambridgeUK
| | - Holly Kimko
- Clinical Pharmacology and Quantitative Pharmacology, CPSS, BioPharmaceuticals R&DAstraZenecaGaithersburgMarylandUSA
| | - Shringi Sharma
- Clinical Pharmacology and Quantitative Pharmacology, CPSS, BioPharmaceuticals R&DAstraZenecaSouth San FranciscoCaliforniaUSA
| | - Giovanni Di Veroli
- Clinical Pharmacology and Quantitative Pharmacology, CPSS, BioPharmaceuticals R&DAstraZenecaCambridgeUK
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6
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Urso A, Martino EA, Cuneo A, Gentile M, Rigolin GM. Chronic Lymphocytic Leukemia: Prognostic Factors in the Era of Novel Drugs. Cancers (Basel) 2024; 16:2732. [PMID: 39123460 PMCID: PMC11311700 DOI: 10.3390/cancers16152732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Novel drugs have profoundly changed the outcomes in chronic lymphocytic leukemia (CLL) patients, and the traditional prognostic factors that were identified in the era of chemoimmunotherapy need to be validated in the context of these new targeted therapies. Currently, the most important prognostic genetic biomarkers are the immunoglobulin heavy chain variable (IGHV) mutational status, genetic aberrations including del(17p)/TP53 abnormalities, and the complex karyotype. In this review, we discuss the prognostic role of these genomic markers in relation to novel treatments. Moreover, we present and discuss new scoring systems that were elaborated and validated in the era of new drugs. In routine clinical practice, the application of an extensive genomic work-up with validated prognostic markers could improve the identification of "very high-risk" CLL patients who could benefit from novel, more effective targeted treatments.
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Affiliation(s)
- Antonio Urso
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
| | | | - Antonio Cuneo
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy; (E.A.M.); (M.G.)
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, 87036 Rende, Italy
| | - Gian Matteo Rigolin
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
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7
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Fürstenau M, Giza A, Weiss J, Kleinert F, Robrecht S, Franzen F, Stumpf J, Langerbeins P, Al-Sawaf O, Simon F, Fink AM, Schneider C, Tausch E, Schetelig J, Dreger P, Böttcher S, Fischer K, Kreuzer KA, Ritgen M, Schilhabel A, Brüggemann M, Stilgenbauer S, Eichhorst B, Hallek M, Cramer P. Acalabrutinib, venetoclax, and obinutuzumab in relapsed/refractory CLL: final efficacy and ctDNA analysis of the CLL2-BAAG trial. Blood 2024; 144:272-282. [PMID: 38620072 DOI: 10.1182/blood.2023022730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/17/2024] Open
Abstract
ABSTRACT The phase 2 CLL2-BAAG trial tested the measurable residual disease (MRD)-guided triple combination of acalabrutinib, venetoclax, and obinutuzumab after optional bendamustine debulking in 45 patients with relapsed/refractory chronic lymphocytic leukemia (CLL). MRD was measured by flow cytometry (FCM; undetectable MRD <10-4) in peripheral blood (PB) and circulating tumor DNA (ctDNA) using digital droplet polymerase chain reaction of variable-diversity-joining (VDJ) rearrangements and CLL-related mutations in plasma. The median number of previous treatments was 1 (range, 1-4); 18 patients (40%) had received a Bruton tyrosine kinase inhibitor (BTKi) and/or venetoclax before inclusion, 14 of 44 (31.8%) had TP53 aberrations, and 34 (75.6%) had unmutated immunoglobulin heavy-chain variable region genes. With a median observation time of 36.3 months and all patients off-treatment for a median of 21.9 months, uMRD <10-4 in PB was achieved in 42 of the 45 patients (93.3%) at any time point, including 17 of 18 (94.4%) previously exposed to venetoclax/BTKi and 13 of 14 (92.9%) with TP53 aberrations. The estimated 3-year progression-free and overall survival rates were 85.0% and 93.8%, respectively. Overall, 585 paired FCM/ctDNA samples were analyzed and 18 MRD recurrences (5 with and 13 without clinical progression) occurred after the end of treatment. Twelve samples were first detected by ctDNA, 3 by FCM, and 3 synchronously. In conclusion, time-limited MRD-guided acalabrutinib, venetoclax, and obinutuzumab achieved deep remissions in almost all patients with relapsed/refractory CLL. The addition of ctDNA-based analyses to FCM MRD assessment seems to improve early detection of relapses. This trial was registered at www.clinicaltrials.gov as #NCT03787264.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Sulfonamides/administration & dosage
- Sulfonamides/therapeutic use
- Aged
- Middle Aged
- Female
- Male
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Circulating Tumor DNA/genetics
- Circulating Tumor DNA/blood
- Pyrazines/administration & dosage
- Pyrazines/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Neoplasm, Residual
- Benzamides/administration & dosage
- Benzamides/therapeutic use
- Adult
- Recurrence
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Affiliation(s)
- Moritz Fürstenau
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Jonathan Weiss
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Fanni Kleinert
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Fabian Franzen
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Janina Stumpf
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Petra Langerbeins
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Florian Simon
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Christof Schneider
- Division of Chronic Lymphocytic Leukemia, Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Eugen Tausch
- Division of Chronic Lymphocytic Leukemia, Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Johannes Schetelig
- Department I of Internal Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Peter Dreger
- Department V of Internal Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian Böttcher
- Department III of Internal Medicine, University Hospital Rostock, Rostock, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anke Schilhabel
- Department II of Internal Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Monika Brüggemann
- Department II of Internal Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stephan Stilgenbauer
- Division of Chronic Lymphocytic Leukemia, Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Department I of Internal Medicine, Faculty of Medicine and University Hospital of Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, German Chronic Lymphocytic Leukemia Study Group, University of Cologne, Cologne, Germany
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8
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Stamatopoulos K, Pavlova S, Al‐Sawaf O, Chatzikonstantinou T, Karamanidou C, Gaidano G, Cymbalista F, Kater AP, Rawstron A, Scarfò L, Ghia P, Rosenquist R. Realizing precision medicine in chronic lymphocytic leukemia: Remaining challenges and potential opportunities. Hemasphere 2024; 8:e113. [PMID: 39035106 PMCID: PMC11260284 DOI: 10.1002/hem3.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/29/2024] [Accepted: 06/04/2024] [Indexed: 07/23/2024] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) exhibit diverse clinical outcomes. An expanding array of genetic tests is now employed to facilitate the identification of patients with high-risk disease and inform treatment decisions. These tests encompass molecular cytogenetic analysis, focusing on recurrent chromosomal alterations, particularly del(17p). Additionally, sequencing is utilized to identify TP53 mutations and to determine the somatic hypermutation status of the immunoglobulin heavy variable gene. Concurrently, a swift advancement of targeted treatment has led to the implementation of novel strategies for patients with CLL, including kinase and BCL2 inhibitors. This review explores both current and emerging diagnostic tests aimed at identifying high-risk patients who should benefit from targeted therapies. We outline existing treatment paradigms, emphasizing the importance of matching the right treatment to the right patient beyond genetic stratification, considering the crucial balance between safety and efficacy. We also take into consideration the practical and logistical issues when choosing a management strategy for each individual patient. Furthermore, we delve into the mechanisms underlying therapy resistance and stress the relevance of monitoring measurable residual disease to guide treatment decisions. Finally, we underscore the necessity of aggregating real-world data, adopting a global perspective, and ensuring patient engagement. Taken together, we argue that precision medicine is not the mere application of precision diagnostics and accessibility of precision therapies in CLL but encompasses various aspects of the patient journey (e.g., lifestyle exposures and comorbidities) and their preferences toward achieving true personalized medicine for patients with CLL.
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Affiliation(s)
- Kostas Stamatopoulos
- Centre for Research and Technology HellasInstitute of Applied BiosciencesThessalonikiGreece
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Sarka Pavlova
- Department of Internal Medicine, Hematology and Oncology, and Institute of Medical Genetics and GenomicsUniversity Hospital Brno and Medical Faculty, Masaryk UniversityBrnoCzech Republic
- Central European Institute of TechnologyMasaryk UniversityBrnoCzech Republic
| | - Othman Al‐Sawaf
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)University of Cologne, Faculty of Medicine and University Hospital of CologneCologneGermany
- Francis Crick Institute LondonLondonUK
- Cancer Institute, University College LondonLondonUK
| | | | - Christina Karamanidou
- Centre for Research and Technology HellasInstitute of Applied BiosciencesThessalonikiGreece
| | - Gianluca Gaidano
- Division of Haematology, Department of Translational MedicineUniversity of Eastern PiedmontNovaraItaly
| | | | - Arnon P. Kater
- Department of Hematology, Cancer Center AmsterdamAmsterdam University Medical Centers, University of AmsterdamAmsterdamThe Netherlands
| | - Andy Rawstron
- Haematological Malignancy Diagnostic ServiceLeeds Teaching Hospitals TrustLeedsUK
| | - Lydia Scarfò
- Medical SchoolUniversità Vita Salute San RaffaeleMilanoItaly
- Strategic Research Program on CLLIRCCS Ospedale San RaffaeleMilanoItaly
| | - Paolo Ghia
- Medical SchoolUniversità Vita Salute San RaffaeleMilanoItaly
- Strategic Research Program on CLLIRCCS Ospedale San RaffaeleMilanoItaly
| | - Richard Rosenquist
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
- Clinical GeneticsKarolinska University HospitalStockholmSweden
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9
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Kutsch N, Robrecht S, Fink A, Lange E, Weide R, Kiehl MG, Sökler M, Schlag R, Vehling‐Kaiser U, Köchling G, Plöger C, Gregor M, Plesner T, Clausen MR, Oschlies I, Ritgen M, Herling M, Fischer K, Döhner H, Wendtner C, Kreuzer K, Stilgenbauer S, Hallek M, Böttcher S, Klapper W, Eichhorst B. The role of trephine bone marrow biopsies in the era of measurable residual disease -Results from the CLL10 trial of the German CLL Study Group (GCLLSG). Hemasphere 2024; 8:e126. [PMID: 39050548 PMCID: PMC11267170 DOI: 10.1002/hem3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/10/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Sandra Robrecht
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Anna Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Elisabeth Lange
- Department of Hematology and OncologyEvangelical Hospital HammHammGermany
| | - Rudolf Weide
- Practice for Hematology and OncologyKoblenzGermany
| | - Michael G. Kiehl
- Department of Internal MedicineFrankfurt (Oder) General HospitalFrankfurt/OderGermany
| | - Martin Sökler
- Department II of Internal MedicineUniversity Hospital TübingenTübingenGermany
- Department of Hematology and OncologyHospital STS AG ThunThunSwitzerland
| | | | | | | | | | - Michael Gregor
- Division of HematologyCantonal Hospital of LucerneLucerneSwitzerland
| | - Torben Plesner
- Department of Hematology and University of Southern DenmarkVejle HospitalVejleDenmark
| | - Michael R. Clausen
- Department of Hematology and University of Southern DenmarkVejle HospitalVejleDenmark
| | - Ilske Oschlies
- Hematopathology SectionChristian‐Albrechts‐University KielKielGermany
| | - Matthias Ritgen
- Department II of Internal MedicineUniversity of Schleswig‐HolsteinKielGermany
| | - Marco Herling
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
- Department of Hematology, Cellular Therapy, Hemostaseology and InfectiologyUniversity Hospital LeipzigLeipzigGermany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Hartmut Döhner
- Department III of Internal MedicineUniversity Hospital of UlmUlmGermany
| | | | - Karl‐Anton Kreuzer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Stephan Stilgenbauer
- Department of Hematology and OncologyHospital STS AG ThunThunSwitzerland
- Department of Hematology, Cellular Therapy, Hemostaseology and InfectiologyUniversity Hospital LeipzigLeipzigGermany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Sebastian Böttcher
- Department III of Internal Medicine Medicine—Hematology/Oncology/Palliative CareRostock University Medical CenterRostockGermany
| | - Wolfram Klapper
- Hematopathology SectionChristian‐Albrechts‐University KielKielGermany
| | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
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10
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Goergen E, Al-Sawaf O. The prognostic significance of genomic complexity in patients with CLL. Leuk Lymphoma 2024; 65:873-881. [PMID: 38593054 DOI: 10.1080/10428194.2024.2333448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
Chromosomal aberrations are a common feature of cancer and can fuel cancer progression and treatment resistance. In chronic lymphocytic leukemia (CLL), the presence of multiple chromosomal aberrations is commonly referred to as "genomic complexity" or "complex karyotype"- (CKT). In the context of chemo- and chemoimmunotherapy, genomic complexity is associated with poor response to treatment and short survival, while some targeted therapies are able to mitigate its adverse prognostic impact. This article reviews currently available data and literature on the role of genomic complexity in CLL. The currently established tools to measure genomic complexity in patients with CLL are summarized and their strengths and weaknesses for routine diagnostics are evaluated. Moreover, possible definitions of CKT as an indicator for genomic complexity are discussed. Finally, data on the impact of CKT on clinical outcomes of patients with CLL are reviewed and the implications for patient stratification are presented.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Prognosis
- Chromosome Aberrations
- Genomics/methods
- Biomarkers, Tumor/genetics
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Affiliation(s)
- Ellinor Goergen
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
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11
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Langerbeins P, Giza A, Robrecht S, Cramer P, von Tresckow J, Al-Sawaf O, Fink AM, Fürstenau M, Kutsch N, Simon F, Goede V, Hoechstetter M, Niemann CU, da Cunha-Bang C, Kater A, Dubois J, Gregor M, Staber PB, Tausch E, Schneider C, Stilgenbauer S, Eichhorst B, Fischer K, Hallek M. Reassessing the chronic lymphocytic leukemia International Prognostic Index in the era of targeted therapies. Blood 2024; 143:2588-2598. [PMID: 38620092 DOI: 10.1182/blood.2023022564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024] Open
Abstract
ABSTRACT We evaluated the chronic lymphocytic leukemia International Prognostic Index (CLL-IPI) in patients with CLL treated first line with targeted drugs (n = 991) or chemoimmunotherapy (n = 1256). With a median observation time of 40.5 months, the 3-year progression-free survival (PFS) rates for targeted drug-treated patients varied by CLL-IPI risk group: 96.5% (low), 87.6% (intermediate), 82.4% (high), and 78.7% (very high). Differences between consecutive CLL-IPI risk groups were observed for intermediate vs low and high vs intermediate, but not very high vs high. CLL-IPI factors β2-microglobulin, immunoglobulin heavy variable (IGHV) status, and TP53 status each retained prognostic value for PFS. The 3-year overall survival (OS) rates by CLL-IPI risk groups were 100%, 96%, 93.9%, and 89.4%, respectively, with no differences between consecutive risk groups. Age, Binet stage, β2-microglobulin, and TP53 status each retained prognostic value for OS. In chemoimmunotherapy patients (median observation time, 66.9 months), 3-year PFS rates for CLL-IPI risk groups were 78.1%, 51.4%, 40.1%, and 16.5%, respectively; corresponding 3-year OS rates were 97.4%, 93.1%, 81.8%, and 57.3%. In a matched-pair analysis, PFS differences in targeted therapies (n = 812) vs chemoimmunotherapy (n = 812) across all risk groups and OS differences in all but patients at low risk were demonstrated. The CLL-IPI maintains its prognostic value in predicting PFS outcomes with targeted drugs, but its impact in predicting survival appears diminished. Targeted therapies showed enhanced outcomes over chemoimmunotherapy, highlighting their effectiveness across various risk groups. Our findings support ongoing assessment of prognostic tools in CLL treatment evolution. These trials were registered at www.ClinicalTrials.gov as #NCT02345863, #NCT02401503, #NCT02689141, #NCT02445131, #NCT02758665, #NCT02950051, #NCT02242942, #NCT00262782, #NCT00281918, and #NCT01010061.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Female
- Male
- Aged
- Middle Aged
- Prognosis
- Aged, 80 and over
- Molecular Targeted Therapy
- Adult
- beta 2-Microglobulin
- Survival Rate
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Affiliation(s)
- Petra Langerbeins
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Paula Cramer
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Julia von Tresckow
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University of Duisburg-Essen, Essen, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Anna Maria Fink
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Moritz Fürstenau
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Nadine Kutsch
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Florian Simon
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Valentin Goede
- Division of Oncogeriatrics, St. Marien Hospital, Cologne, Germany
| | - Manuela Hoechstetter
- Interdisciplinary Oncology Center Munich, Outpatient Clinic, Day Hospital, Center for Clinical Trials, Hematology and Oncology, Munich, Germany
| | | | | | - Arnon Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Julie Dubois
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael Gregor
- Division of Hematology, Luzerner Kantonspital, Lucerne, Switzerland
| | - Philipp Bernhard Staber
- Division of Hematology and Hemostaseology, Medicine I, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Department of Internal Medicine I, Vienna, Austria
| | - Eugen Tausch
- Department of Internal Medicine III, Division of CLL, University Hospital Ulm, Ulm, Germany
| | - Christof Schneider
- Department of Internal Medicine III, Division of CLL, University Hospital Ulm, Ulm, Germany
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Division of CLL, University Hospital Ulm, Ulm, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine and German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
- Cologne Cluster of Excellence for Stress Responses in Aging-Associated Diseases, Clinical Research Unit, University of Cologne, Cologne, Germany
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12
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Javidi-Sharifi N, Brown JR. Evaluating zanubrutinib for the treatment of adults with chronic lymphocytic leukemia or small lymphocytic lymphoma. Expert Rev Hematol 2024; 17:201-210. [PMID: 38784995 DOI: 10.1080/17474086.2024.2356257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION This review evaluates zanubrutinib as a treatment option for adults with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Zanubrutinib, a covalent BTK (Bruton's tyrosine kinase) inhibitor, was recently approved by the US FDA based in part on head-to-head data demonstrating improved efficacy and safety compared to ibrutinib. AREAS COVERED The review discusses the efficacy, safety, and comparative advantages of zanubrutinib, highlighting its safety profile compared to other BTK inhibitors. It also addresses the unmet needs of current therapies in CLL/SLL and provides an overview of competitor compounds and ongoing research in BTK inhibition. EXPERT OPINION Zanubrutinib, the first BTK inhibitor to demonstrate superior efficacy and safety compared to another BTK inhibitor in CLL, is likely to be widely adopted due to its high-quality data and ease of use. Looking ahead, pirtobrutinib, a novel non-covalent BTK inhibitor, has shown promise in heavily pretreated CLL patients, including those unresponsive to covalent inhibitors, with ongoing phase 3 trials comparing it against ibrutinib. The field is also exploring time-limited therapies like the combination of ibrutinib and venetoclax, with ongoing trials evaluating different combinations to optimize efficacy and minimize toxicity, indicating a promising future for combination therapies in CLL treatment.
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Affiliation(s)
- Nathalie Javidi-Sharifi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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13
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Del Giudice I, Della Starza I, De Falco F, Gaidano G, Sportoletti P. Monitoring Response and Resistance to Treatment in Chronic Lymphocytic Leukemia. Cancers (Basel) 2024; 16:2049. [PMID: 38893168 PMCID: PMC11171231 DOI: 10.3390/cancers16112049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/09/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
The recent evolution in chronic lymphocytic leukemia (CLL) targeted therapies led to a progressive change in the way clinicians manage the goals of treatment and evaluate the response to treatment in respect to the paradigm of the chemoimmunotherapy era. Continuous therapies with BTK inhibitors achieve prolonged and sustained control of the disease. On the other hand, venetoclax and anti-CD20 monoclonal antibodies or, more recently, ibrutinib plus venetoclax combinations, given for a fixed duration, achieve undetectable measurable residual disease (uMRD) in the vast majority of patients. On these grounds, a time-limited MRD-driven strategy, a previously unexplored scenario in CLL, is being attempted. On the other side of the spectrum, novel genetic and non-genetic mechanisms of resistance to targeted treatments are emerging. Here we review the response assessment criteria, the evolution and clinical application of MRD analysis and the mechanisms of resistance according to the novel treatment strategies within clinical trials. The extent to which this novel evidence will translate in the real-life management of CLL patients remains an open issue to be addressed.
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Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
| | - Irene Della Starza
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
- AIL Roma, ODV, 00161 Rome, Italy
| | - Filomena De Falco
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
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14
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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A. Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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15
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Wang WD, Gale RP, Liang Y. Chronic Lymphocytic Leukemia Therapy Guided by Measurable Residual Disease. N Engl J Med 2024; 390:1633-1634. [PMID: 38692303 DOI: 10.1056/nejmc2402472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Neoplasm, Residual/blood
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/drug therapy
- Bone Marrow/pathology
- Survival Analysis
- Randomized Controlled Trials as Topic
- Rituximab/administration & dosage
- Cyclophosphamide/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers/analysis
- Biomarkers/blood
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Affiliation(s)
- Wei-da Wang
- Sun Yet-sen University Cancer Center, Guangzhou, China
| | | | - Yang Liang
- Sun Yet-sen University Cancer Center, Guangzhou, China
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16
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Mouhssine S, Maher N, Kogila S, Cerchione C, Martinelli G, Gaidano G. Current Therapeutic Sequencing in Chronic Lymphocytic Leukemia. Hematol Rep 2024; 16:270-282. [PMID: 38804280 PMCID: PMC11130833 DOI: 10.3390/hematolrep16020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/20/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
The treatment landscape of chronic lymphocytic leukemia (CLL), the most frequent leukemia in adults, is constantly changing. CLL patients can be divided into three risk categories, based on their IGHV mutational status and the occurrence of TP53 disruption and/or complex karyotype. For the first-line treatment of low- and intermediate-risk CLL, both the BCL2 inhibitor venetoclax plus obinutuzumab and the second generation BTK inhibitors (BTKi), namely acalabrutinib and zanubrutinib, are valuable and effective options. Conversely, venetoclax-based fixed duration therapies have not shown remarkable results in high-risk CLL patients, while continuous treatment with acalabrutinib and zanubrutinib displayed favorable outcomes, similar to those obtained in TP53 wild-type patients. The development of acquired resistance to pathway inhibitors is still a clinical challenge, and the optimal treatment sequencing of relapsed/refractory CLL is not completely established. Covalent BTKi-refractory patients should be treated with venetoclax plus rituximab, whereas venetoclax-refractory CLL may be treated with second generation BTKi in the case of early relapse, while venetoclax plus rituximab might be used if late relapse has occurred. On these grounds, here we provide an overview of the current state-of-the-art therapeutic algorithms for treatment-naïve patients, as well as for relapsed/refractory disease.
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Affiliation(s)
- Samir Mouhssine
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Nawar Maher
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Sreekar Kogila
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Claudio Cerchione
- Hematology Unit, Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori”—IRST IRCCS, 47014 Meldola, Italy;
| | - Giovanni Martinelli
- Department of Hematology and Sciences Oncology, Institute of Haematology “L. and A. Seràgnoli”, S. Orsola University Hospital, 40138 Bologna, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
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17
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Bajwa A, Habib A, Kittai AS. Treatment of Richter's Transformation with Novel Therapies. Curr Hematol Malig Rep 2024; 19:45-55. [PMID: 38194201 PMCID: PMC10894755 DOI: 10.1007/s11899-023-00721-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review presents recently published clinical trial data and ongoing investigations regarding the treatment of Richter's transformation (RT). RECENT FINDINGS Recently, numerous approaches have been investigated for the treatment of RT including: traditional chemoimmunotherapy regimens combined with targeted agents such as BTKi and BCL2i; immunotherapy combined with targeted agents; non-covalent BTKis; bispecific T cell engagers; and CART therapy. In addition, various novel targeted agents are currently being studied for the treatment of RT in phase 1 and 2 clinical trials. Standard of care treatment with chemoimmunotherapy for RT has limited efficacy in achieving durable remissions. Here, we review recent data on the use of combination treatments and targeted agents in RT. Although some progress has been made in the investigation to optimize treatment of RT, further study is needed to evaluate long term outcomes of recently published trials and test efficacy of upcoming novel agents.
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Affiliation(s)
- Amneet Bajwa
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Alma Habib
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Adam S Kittai
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA.
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18
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Tausch E, López C, Stilgenbauer S, Siebert R. Genetic alterations in chronic lymphocytic leukemia and plasma cell neoplasms - a practical guide to WHO HAEM5. MED GENET-BERLIN 2024; 36:47-57. [PMID: 38835970 PMCID: PMC11006374 DOI: 10.1515/medgen-2024-2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
The 5th edition of the World Health Organization Classification of Haematolymphoid Tumours (WHO-HAEM5) provides a revised classification of lymphoid malignancies including chronic lymphocytic leukemia (CLL) and plasma cell myeloma/multiple myeloma (PCM/MM). For both diseases the descriptions of precursor states such as monoclonal B-cell lymphocytosis and monoclonal gammopathy of uncertain significance (MGUS) have been updated including a better risk stratification model. New insights on mutational landscapes and branching evolutionary pattern were embedded as diagnostic and prognostic factors, accompanied by a revised structure for the chapter of plasma cell neoplasms. Thus, the WHO-HAEM5 leads to practical improvements of biological and clinical relevance for pathologists, clinicians, geneticists and scientists in the field of lymphoid malignancies. The present review gives an overview on the landscape of genetic alterations in CLL and plasma cell neoplasms with a focus on their impact on classification and treatment.
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Affiliation(s)
- Eugen Tausch
- Ulm University Division of CLL, Department of Internal Medicine 3 Ulm Germany
| | - Cristina López
- Institut d'Investigacions Biomèdiques August Phi i Sunyer (IDIBAPS) Barcelona Spain
| | | | - Reiner Siebert
- Ulm University and Ulm University Medical Center Institute of Human Genetics Ulm Germany
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19
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Kater AP, Arslan Ö, Demirkan F, Herishanu Y, Ferhanoglu B, Diaz MG, Leber B, Montillo M, Panayiotidis P, Rossi D, Skarbnik A, Tempescul A, Turgut M, Mellink CH, van der Kevie-Kersemaekers AMF, Lanham S, Sale B, Del Rio L, Popovic R, Chyla BJ, Busman T, Komlosi V, Wang X, Sail K, Pena GE, Vizkelety T, Forconi F. Activity of venetoclax in patients with relapsed or refractory chronic lymphocytic leukaemia: analysis of the VENICE-1 multicentre, open-label, single-arm, phase 3b trial. Lancet Oncol 2024; 25:463-473. [PMID: 38467131 DOI: 10.1016/s1470-2045(24)00070-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/09/2024] [Accepted: 01/26/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Most patients with chronic lymphocytic leukaemia progress after treatment or retreatment with targeted therapy or chemoimmunotherapy and have limited subsequent treatment options. Response levels to the single-agent venetoclax in the relapsed setting is unknown. We aimed to assess venetoclax activity in patients with or without previous B-cell receptor-associated kinase inhibitor (BCRi) treatment. METHODS This multicentre, open-label, single-arm, phase 3b trial (VENICE-1) assessed activity and safety of venetoclax monotherapy in adults with relapsed or refractory chronic lymphocytic leukaemia, stratified by previous exposure to a BCRi. Eligible participants were aged 18 years or older with previously treated relapsed or refractory chronic lymphocytic leukaemia. Presence of del(17p) or TP53 aberrations and previous BCRi treatment were permitted. Patients received 5-week ramp-up to 400 mg of oral venetoclax once daily and were treated for up to 108 weeks, with 2 years follow-up after discontinuation, or optional extended access. The primary activity endpoint was complete remission rate (complete remission or complete remission with incomplete marrow recovery) in BCRi-naive patients. Analyses used the intent-to-treat (ie, all enrolled patients, which coincided with those who received at least one dose of venetoclax). This study was registered with ClinicalTrials.gov, NCT02756611, and is complete. FINDINGS Between June 22, 2016, and March 11, 2022, we enrolled 258 patients with relapsed or refractory chronic lymphocytic leukaemia (180 [70%] were male; 252 [98%] were White; 191 were BCRi-naive and 67 were BCRi-pretreated). Median follow-up in the overall cohort was 49·5 months (IQR 47·2-54·1), 49·2 months (47·2-53·2) in the BCRi-naive group, and 49·7 months (47·4-54·3) in the BCRi-pretreated group. Of 191 BCRi-naive patients, 66 (35%; 95% CI 27·8-41·8) had complete remission or complete remission with incomplete marrow recovery. 18 (27%; 95% CI 16·8-39·1) of 67 patients in the BCRi-pretreated group had complete remission or complete remission with incomplete marrow recovery. Grade 3 or worse treatment-emergent adverse events were reported in 203 (79%) and serious adverse events were reported in 136 (53%) of 258 patients in the overall cohort. The most common treatment-emergent adverse event was neutropenia (96 [37%]) and the most common and serious adverse event was pneumonia (21 [8%]). There were 13 (5%) deaths reported due to adverse events; one of these deaths (autoimmune haemolytic anaemia) was possibly related to venetoclax. No new safety signals were identified. INTERPRETATION These data demonstrate deep and durable responses with venetoclax monotherapy in patients with relapsed or refractory chronic lymphocytic leukaemia, including BCRi-pretreated patients, suggesting that venetoclax monotherapy is an effective strategy for treating BCRi-naive and BCRi-pretreated patients. FUNDING AbbVie.
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Affiliation(s)
- Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Önder Arslan
- Department of Hematology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Fatih Demirkan
- Department of Hematology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Yair Herishanu
- Department of Hematology, Tel-Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Burhan Ferhanoglu
- Department of Hematology, Koç University Medical Faculty, Istanbul, Turkey
| | - Marcos Gonzalez Diaz
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Brian Leber
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Marco Montillo
- Department of Haematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Panayiotis Panayiotidis
- First Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, Laikon University Hospital, Athens, Greece
| | - Davide Rossi
- Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Alan Skarbnik
- Lymphoproliferative Disorders Program, Novant Health Cancer Institute, Charlotte, NC, USA; John Theurer Cancer Center, Hackensack, NJ, USA
| | - Adrian Tempescul
- Department of Clinical Hematology, University Teaching Hospital Brest, Brest, France
| | - Mehmet Turgut
- Department of Hematology, Ondokuz Mayıs University Faculty of Medicine, Samsun, Turkey
| | - Clemens H Mellink
- Department of Human Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Stuart Lanham
- Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ben Sale
- Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Luis Del Rio
- Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | | | | | | | | | | | | | | | | | - Francesco Forconi
- Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Haematology Department, Cancer Care Directorate, University Hospital Southampton NHS Trust, Southampton, UK.
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20
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Ahn IE, Davids MS. Therapeutic targeting of apoptosis in chronic lymphocytic leukemia. Semin Hematol 2024; 61:109-118. [PMID: 38538512 DOI: 10.1053/j.seminhematol.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 06/09/2024]
Abstract
Therapeutic targeting of apoptosis with small molecule B-cell lymphoma 2 (BCL-2) inhibition with venetoclax is highly efficacious in CLL, leading to sustained deep responses, particularly among patients with treatment-naïve disease with favorable prognostic markers. Patients with unfavorable genetic characteristics such as TP53 aberration and unmutated IGHV may also derive durable benefits, but their remission duration after time-limited venetoclax-containing combination therapy is shorter, particularly in patients with relapsed/refractory disease. Emerging data indicate that the context of disease progression after initial treatment with venetoclax may define the success of re-treatment with venetoclax. Specifically, continuous venetoclax exposure may select for resistant disease due to genetic mechanisms such as BCL2 mutations and functional resistance mechanisms such as hyperphosphorylation of BCL-2 family proteins, which decrease the affinity of venetoclax binding to the target or lead to increased MCL-1 dependence and concomitant decrease in BCL-2 dependence. These patients may be best served by switching to a different class of targeted agents at the time of progression. In contrast, relapsed CLL that arises while being off therapy after a period of time-limited venetoclax-based regimens maintains sensitivity to re-treatment with venetoclax for the majority of patients. Novel strategies related to therapeutic targeting of apoptosis include next-generation BCL-2 inhibitors with improved potency and pharmacokinetic profiles, direct targeting of anti-apoptotic BH3 family proteins beyond BCL-2 such as MCL-1, and indirect targeting of MCL-1 through mechanisms such as small molecule cyclin-dependent kinase 9 inhibitors.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Apoptosis/drug effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/metabolism
- Sulfonamides/therapeutic use
- Sulfonamides/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Molecular Targeted Therapy/methods
- Drug Resistance, Neoplasm/drug effects
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Affiliation(s)
- Inhye E Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
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21
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Moia R, Gaidano G. Prognostication in chronic lymphocytic leukemia. Semin Hematol 2024; 61:83-90. [PMID: 38523019 DOI: 10.1053/j.seminhematol.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. CLL is a highly heterogeneous disease: some patients may never require therapy and others relapse several times after different therapeutic strategies. Therefore, in CLL, prognostic markers are essential to capture high-risk patients for different clinical endpoints including early treatment requirement, early progression after BTK or BCL2 inhibitors and Richter transformation. In early stage CLL, different biological and clinical biomarkers have been identified to predict time to treatment requirement that could be used to identify the most appropriate population for early intervention clinical trial. However, at the moment, the standard of care for early stage CLL remains watch & wait since no survival benefit has been identified in clinical trials with chemoimmunotherapy and with BTK inhibitors. In patients requiring treatment TP53 disruptions identify high-risk patients who benefit the most from long-term continuous therapy with BTKi. On the opposite side of the spectrum, IGHV mutated patients devoid of TP53 disruption benefit the most from fixed-duration therapy with venetoclax-obinutuzumab. In between, the highly heterogenous subgroup of patients with IGHV unmutated genes represents the group in which further efforts are needed to identify additional prognostic biomarkers aimed at selecting patients who can benefit from fixed-duration and patients who can benefit from long term BTKi therapy. In the context of the aggressive transformation of CLL, namely Richter syndrome, the clonal relationship to the CLL counterpart represents the strongest prognostic biomarker. Clonally related Richter syndrome still represents an unmet clinical need which requires further efforts to identify new therapeutic strategies.
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MESH Headings
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Humans
- Prognosis
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Mutation
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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22
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Molica S, Allsup D. Fixed-duration therapy comes of age in CLL: long-term results of MURANO and CLL14 trials. Expert Rev Anticancer Ther 2024; 24:101-106. [PMID: 38014557 DOI: 10.1080/14737140.2023.2288899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/24/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) management has witnessed a transformative shift with the advent of time-limited venetoclax and anti-CD20 monoclonal antibody (mAb) regimens, as exemplified by the groundbreaking MURANO and CLL14 trials. AREA COVERED This article delves into the long-term follow-up data of fixed duration (FD) venetoclax combined with anti-CD20 mAb across various lines of CLL therapy. The data discussed here, not yet available in current literature, was unveiled at the 23rd European Hematological Association (EHA) congress held in Frankfurt in June 2023. EXPERT OPINION Combinations of venetoclax with anti-CD20 mAbs represent a compelling therapeutic option due to their finite treatment duration and remarkable achievement of undetectable minimal residual disease (uMRD). This not only ensures more enduring responses but also presents a manageable toxicity profile that suits a broad spectrum of CLL patients, including those who are elderly or less medically fit.Importantly, the integration of venetoclax/anti-CD20 mAb FD regimens may diminish the likelihood of CLL patients developing target mutations. This, in turn, enhances the potential for eliciting secondary clinical responses upon retreatment with venetoclax. Additionally, from an economic perspective, the cost-effectiveness of targeted therapy may further advocate for the selection of FD therapy as a frontrunner in CLL treatment.
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Affiliation(s)
- Stefano Molica
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
| | - David Allsup
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
- Centre of Biomedicine, Hull York Medical School, University of Hull, Hull, UK
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23
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Liu Y, Ho C, Yu W, Huang Y, Miller J, Gao Q, Syed M, Ma Y, Wang M, Maciag L, Petrova-Drus K, Zhu M, Yao J, Vanderbilt C, Durham B, Benhamida J, Ewalt MD, Dogan A, Roshal M, Nafa K, Arcila ME. Quantification of Measurable Residual Disease Detection by Next-Generation Sequencing-Based Clonality Testing in B-Cell and Plasma Cell Neoplasms. J Mol Diagn 2024; 26:168-178. [PMID: 38103591 PMCID: PMC10918645 DOI: 10.1016/j.jmoldx.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023] Open
Abstract
Next-generation sequencing (NGS)-based measurable residual disease (MRD) monitoring in post-treatment settings can be crucial for relapse risk stratification in patients with B-cell and plasma cell neoplasms. Prior studies have focused on validation of various technical aspects of the MRD assays, but more studies are warranted to establish the performance characteristics and enable standardization and broad utilization in routine clinical practice. Here, the authors describe an NGS-based IGH MRD quantification assay, incorporating a spike-in calibrator for monitoring B-cell and plasma cell neoplasms based on their unique IGH rearrangement status. Comparison of MRD status (positive or undetectable) by NGS and flow cytometry (FC) assays showed high concordance (91%, 471/519 cases) and overall good linear correlation in MRD quantitation, particularly for chronic lymphocytic leukemia and B-lymphoblastic leukemia/lymphoma (R = 0.85). Quantitative correlation was lower for plasma cell neoplasms, where underestimation by FC is a known limitation. No significant effects on sequencing efficiency by the spike-in calibrator were observed, with excellent inter- and intra-assay reproducibility within the authors' laboratory, and in comparison to an external laboratory, using the same assay and protocols. Assays performed both at internal and external laboratories showed highly concordant MRD detection (100%) and quantitation (R = 0.97). Overall, this NGS-based MRD assay showed highly reproducible results with quantitation that correlated well with FC MRD assessment, particularly for B-cell neoplasms.
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Affiliation(s)
- Ying Liu
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Caleb Ho
- Loxo Oncology, Inc., Stamford, Connecticut
| | - Wayne Yu
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ying Huang
- Invivoscribe, Inc., San Diego, California
| | | | - Qi Gao
- Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mustafa Syed
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuanyuan Ma
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meiyi Wang
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lidia Maciag
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kseniya Petrova-Drus
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Menglei Zhu
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - JinJuan Yao
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chad Vanderbilt
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Benjamin Durham
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamal Benhamida
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mark D Ewalt
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Dogan
- Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Mikhail Roshal
- Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Khedoudja Nafa
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria E Arcila
- Diagnostic Molecular Pathology, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Hematopathology Service, Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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24
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Anderson MA, Walewska R, Hackett F, Kater AP, Montegaard J, O'Brien S, Seymour JF, Smith M, Stilgenbauer S, Whitechurch A, Brown JR. Venetoclax Initiation in Chronic Lymphocytic Leukemia: International Insights and Innovative Approaches for Optimal Patient Care. Cancers (Basel) 2024; 16:980. [PMID: 38473342 DOI: 10.3390/cancers16050980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 03/14/2024] Open
Abstract
Venetoclax, a highly selective, oral B-cell lymphoma 2 inhibitor, provides a robust targeted-therapy option for the treatment of chronic lymphocytic leukemia (CLL), including patients with high-risk del(17p)/mutated-TP53 and immunoglobulin heavy variable region unmutated CLL and those refractory to chemoimmunotherapy across all age groups. Due to the potent pro-apoptotic effect of venetoclax, treatment initiation carries a risk of tumor lysis syndrome (TLS). Prompt and appropriate management is needed to limit clinical TLS, which may entail serious adverse events and death. Venetoclax ramp-up involves gradual, stepwise increases in daily venetoclax dosing from 20 mg to 400 mg (target dose) over 5 weeks; adherence to on-label scheduling provides a tumor debulking phase, reducing the risk of TLS. The key components of safe venetoclax therapy involve assessment (radiographic evaluation and baseline blood chemistry), preparation (adequate hydration), and initiation (blood chemistry monitoring). In addition to summarizing the evidence for venetoclax's efficacy and safety, this review uses hypothetical patient scenarios based on risk level for TLS (high, medium, low) to share the authors' clinical experience with venetoclax initiation and present global approaches utilized in various treatment settings. These hypothetical scenarios highlight the importance of a multidisciplinary approach and shared decision-making, outlining best practices for venetoclax initiation and overall optimal treatment strategies in patients with CLL.
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Affiliation(s)
- Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC 3000, Australia
- Division of Blood Cells and Blood Cancers, The Walter and Eliza Hall Institute, Melbourne, VIC 3000, Australia
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Renata Walewska
- University Hospitals Dorset, NHS Foundation Trust, Bournemouth BH7 7DW, UK
| | - Fidelma Hackett
- Cancer Services Directorate, University Hospital Limerick UL Hospitals Group, St. Nessan's Road, V94 F858 Limerick, Ireland
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
| | - Josie Montegaard
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA 92868, USA
| | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Matthew Smith
- Department of Haematology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield S44 5BL, UK
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, 89081 Ulm, Germany
| | - Ashley Whitechurch
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC 3000, Australia
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
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25
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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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26
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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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Al-Sawaf O, Davids MS. Overcoming Resistance in Chronic Lymphocytic Leukemia-Maybe Less Is More? Clin Cancer Res 2024; 30:471-473. [PMID: 38055246 PMCID: PMC10841601 DOI: 10.1158/1078-0432.ccr-23-2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
Acquired mutations in BTK, PLCG2, and BCL2 are associated with resistance to continuous targeted agent therapy in chronic lymphocytic leukemia (CLL). Here, we discuss new evidence that limiting the duration of CLL therapy may prevent the evolution of such resistance mutations, potentially facilitating effective retreatment strategies. See related article by Jain et al., p. 498.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany
- Cancer Institute, University College London, United Kingdom
- Francis Crick Institute, London, United Kingdom
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, United States of America
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Munir T, Cairns DA, Bloor A, Allsup D, Cwynarski K, Pettitt A, Paneesha S, Fox CP, Eyre TA, Forconi F, Elmusharaf N, Kennedy B, Gribben J, Pemberton N, Sheehy O, Preston G, Schuh A, Walewska R, Duley L, Howard D, Hockaday A, Jackson S, Greatorex N, Girvan S, Bell S, Brown JM, Webster N, Dalal S, de Tute R, Rawstron A, Patten PEM, Hillmen P. Chronic Lymphocytic Leukemia Therapy Guided by Measurable Residual Disease. N Engl J Med 2024; 390:326-337. [PMID: 38078508 DOI: 10.1056/nejmoa2310063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The combination of ibrutinib and venetoclax has been shown to improve outcomes in patients with chronic lymphocytic leukemia (CLL) as compared with chemoimmunotherapy. Whether ibrutinib-venetoclax and personalization of treatment duration according to measurable residual disease (MRD) is more effective than fludarabine-cyclophosphamide-rituximab (FCR) is unclear. METHODS In this phase 3, multicenter, randomized, controlled, open-label platform trial involving patients with untreated CLL, we compared ibrutinib-venetoclax and ibrutinib monotherapy with FCR. In the ibrutinib-venetoclax group, after 2 months of ibrutinib, venetoclax was added for up to 6 years of therapy. The duration of ibrutinib-venetoclax therapy was defined by MRD assessed in peripheral blood and bone marrow and was double the time taken to achieve undetectable MRD. The primary end point was progression-free survival in the ibrutinib-venetoclax group as compared with the FCR group, results that are reported here. Key secondary end points were overall survival, response, MRD, and safety. RESULTS A total of 523 patients were randomly assigned to the ibrutinib-venetoclax group or the FCR group. At a median of 43.7 months, disease progression or death had occurred in 12 patients in the ibrutinib-venetoclax group and 75 patients in the FCR group (hazard ratio, 0.13; 95% confidence interval [CI], 0.07 to 0.24; P<0.001). Death occurred in 9 patients in the ibrutinib-venetoclax group and 25 patients in the FCR group (hazard ratio, 0.31; 95% CI, 0.15 to 0.67). At 3 years, 58.0% of the patients in the ibrutinib-venetoclax group had stopped therapy owing to undetectable MRD. After 5 years of ibrutinib-venetoclax therapy, 65.9% of the patients had undetectable MRD in the bone marrow and 92.7% had undetectable MRD in the peripheral blood. The risk of infection was similar in the ibrutinib-venetoclax group and the FCR group. The percentage of patients with cardiac serious adverse events was higher in the ibrutinib-venetoclax group than in the FCR group (10.7% vs. 0.4%). CONCLUSIONS MRD-directed ibrutinib-venetoclax improved progression-free survival as compared with FCR, and results for overall survival also favored ibrutinib-venetoclax. (Funded by Cancer Research UK and others; FLAIR ISRCTN Registry number, ISRCTN01844152; EudraCT number, 2013-001944-76.).
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Affiliation(s)
- Talha Munir
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - David A Cairns
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Adrian Bloor
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - David Allsup
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Kate Cwynarski
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Andrew Pettitt
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Shankara Paneesha
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Christopher P Fox
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Toby A Eyre
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Francesco Forconi
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nagah Elmusharaf
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Ben Kennedy
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - John Gribben
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nicholas Pemberton
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Oonagh Sheehy
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Gavin Preston
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Anna Schuh
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Renata Walewska
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Lelia Duley
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Dena Howard
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Anna Hockaday
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sharon Jackson
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Natasha Greatorex
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sean Girvan
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sue Bell
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Julia M Brown
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nichola Webster
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Surita Dalal
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Ruth de Tute
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Andrew Rawstron
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Piers E M Patten
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Peter Hillmen
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
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Del Giudice I, Foà R. Measurable residual disease in chronic lymphocytic leukemia. Where do we stand? Leukemia 2023; 37:2339-2342. [PMID: 37838758 DOI: 10.1038/s41375-023-02066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
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Autore F, Innocenti I, Reda G, Visentin A, Vitale C, Piciocchi A, Fresa A, Leone MMA, Farina L, Quaresmini G, Baratè C, Giordano A, Ferrari A, Angeletti I, De Paolis MR, Malerba L, Chiurazzi F, Loseto G, Catania G, Sportoletti P, Scortechini I, Moia R, Gentile M, Rigolin GM, Mattiello V, Gattei V, Coscia M, Trentin L, Foà R, Cuneo A, Laurenti L. Lymphadenopathy as a predictor of progression during venetoclax treatment in chronic lymphocytic leukemia. A campus chronic lymphocytic leukemia study. Hematol Oncol 2023; 41:877-883. [PMID: 37392141 DOI: 10.1002/hon.3199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/30/2023] [Accepted: 06/17/2023] [Indexed: 07/03/2023]
Abstract
Clinical or biological parameters useful to predict progression during treatment in real-life setting with ibrutinib, idelalisib and venetoclax in relapsed/refractory chronic lymphocytic leukemia (CLL) are still debated. We conducted a multi-center retrospective study on CLL patients treated with ibrutinib and/or idelalisib who were switched to venetoclax for progression or due to adverse events to identify any clinical and/or biological parameters useful to predict progression during treatment with venetoclax. Of all the 128 evaluable patients, 81 had received ibrutinib prior to switching to venetoclax, 35 had received idelalisib and 12 both. When comparing the three subgroups, we did not notice any statistical difference in terms of clinical or biological features. No variable at baseline and at different time points during the follow-up (at 6, 12, 18 and 24 months) was found to predict progression nor to have significance for Progression Free Survival (PFS) in the ibrutinib group and in the idelalisib group and in subgroups according to the line of treatment. Analyzing the data of the venetoclax treatment, after a median follow up of 14.3 months, median PFS was not reached and estimated 3-year PFS was 54%. Of the 128 patients treated with venetoclax, 28 (22%) experienced progressive disease. At multivariate analysis for predictive factors for progression, lymph node diameter >56.5 mm before starting treatment emerged as an independent risk factor for progression. The lymph node predictive role for progression during venetoclax treatment could be a new parameter that deserves to be investigate in future studies.
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Affiliation(s)
- Francesco Autore
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Idanna Innocenti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | - Candida Vitale
- A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Alberto Fresa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Lucia Farina
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | - Angela Ferrari
- Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | | | - Lara Malerba
- A.O. Ospedali San Salvatore di Pesaro, Pesaro, Italy
| | | | | | | | - Paolo Sportoletti
- Centro di Ricerca Emato-Oncologica (CREO), Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | | | - Riccardo Moia
- Università del Piemonte Orientale, A.O.U. Maggiore della Carità, Novara, Italy
| | - Massimo Gentile
- AO di Cosenza, Presidio Ospedaliero Annunziata, Cosenza, Italy
| | | | | | - Valter Gattei
- Centro di Riferimento Oncologico di Aviano IRCCS, Aviano, Italy
| | - Marta Coscia
- A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Robin Foà
- Policlinico Umberto I, Università Sapienza, Roma, Italy
| | - Antonio Cuneo
- A.O.U. Arcispedale S. Anna, Università di Ferrara, Ferrara, Italy
| | - Luca Laurenti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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31
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Niemann CU, Munir T, Moreno C, Owen C, Follows GA, Benjamini O, Janssens A, Levin MD, Robak T, Simkovic M, Voloshin S, Vorobyev V, Yagci M, Ysebaert L, Qi K, Qi Q, Sinet P, Parisi L, Srinivasan S, Schuier N, Baeten K, Howes A, Caces DB, Kater AP. Fixed-duration ibrutinib-venetoclax versus chlorambucil-obinutuzumab in previously untreated chronic lymphocytic leukaemia (GLOW): 4-year follow-up from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 2023; 24:1423-1433. [PMID: 37944541 DOI: 10.1016/s1470-2045(23)00452-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In the GLOW study, fixed-duration ibrutinib-venetoclax showed superior progression-free survival versus chlorambucil-obinutuzumab in patients with previously untreated chronic lymphocytic leukaemia who were older or had comorbidities, or both, at a median follow up of 27·7 months. In this Article, we report updated outcomes from GLOW after a 46-month median follow-up. METHODS GLOW was a randomised, multicentre, phase 3 study done at 67 hospital centres across 14 countries. Patients aged 65 years and older or 18-64 years with previously untreated chronic lymphocytic leukaemia and a cumulative illness rating scale score of more than 6 or creatinine clearance less than 70 mL/min, or both, and an Eastern Cooperative Oncology Group performance status of 2 or less were randomly assigned (1:1) via an interactive web system with permuted blocks (block size of four) and stratified by IGHV mutational status and the presence of del11q aberration to the ibrutinib-venetoclax group (three cycles of ibrutinib lead-in [420 mg/day, orally], followed by 12 cycles of ibrutinib plus venetoclax [400 mg/day, orally, including a 5-week dose ramp-up]) or the chlorambucil-obinutuzumab group (six cycles of chlorambucil [0·5 mg/kg, orally, on days 1 and 15 of each cycle], and obinutuzumab [1000 mg, intravenously, on days 1 (or 100 mg on day 1 and 900 mg on day 2), 8, and 15 of cycle 1 and day 1 of cycles 2-6]). The primary endpoint was progression-free survival in the intention-to-treat population, assessed by an independent review committee. The safety population included all randomised patients who received at least one dose of the study treatment. This study is registered with ClinicalTrials.gov (NCT03462719) and the EU Clinical Trials Register (EudraCT 2017-004699-77). FINDINGS Between May 4, 2018, and April 5, 2019, 211 patients (122 [58%] were male and 89 [42%] were female) were randomly assigned to receive ibrutinib-venetoclax (n=106) or chlorambucil-obinutuzumab (n=105). At a median of 46 months (IQR 43-47) of follow-up, progression-free survival remained superior for the ibrutinib-venetoclax group (hazard ratio 0·214 [95% CI 0·138-0·334]; p<0·0001); 42-month progression-free survival rates were 74·6% (95% CI 65·0-82·0) for ibrutinib-venetoclax and 24·8% (16·5-34·1) for chlorambucil-obinutuzumab. Following the primary analysis, one patient in the chlorambucil-obinutuzumab group had a serious adverse event of myelodysplastic syndrome. Treatment-related deaths were reported in one patient receiving ibrutinib-venetoclax (cardiac failure, pneumonia, and sinus node dysfunction) and in one patient receiving chlorambucil-obinutuzumab (pneumonia). There were 15 deaths in the ibrutinib-venetoclax group (of which three were due to post-treatment infections) and 30 deaths in the chlorambucil-obinutuzumab group (of which 10 were due to post-treatment infections). INTERPRETATION After 4 years of follow-up, ibrutinib-venetoclax continues to significantly prolong progression-free survival (vs chemoimmunotherapy) in patients with previously untreated chronic lymphocytic leukaemia, supporting its use as a first-line option. FUNDING Janssen Research & Development and Pharmacyclics.
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Affiliation(s)
- Carsten U Niemann
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | | | | | | | | | | | - Tadeusz Robak
- Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Martin Simkovic
- 4th Department of Internal Medicine-Haematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Hradec Králové, Czech Republic
| | - Sergey Voloshin
- Russian Scientific and Research Institute of Hematology and Transfusiology, St Petersburg, Russia
| | | | - Munci Yagci
- Gazi Universitesi Tip Fakultesi, Ankara, Türkiye
| | - Loic Ysebaert
- Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Keqin Qi
- Janssen Research & Development, Titusville, NJ, USA
| | - Qianya Qi
- Janssen Research & Development, Raritan, NJ, USA
| | - Pierre Sinet
- Janssen Research & Development, Bridgewater, NJ, USA
| | - Lori Parisi
- Janssen Research & Development, Raritan, NJ, USA
| | - Srimathi Srinivasan
- Oncology Translational Research, Janssen Research & Development, Lower Gwynedd Township, PA, USA
| | | | - Kurt Baeten
- Janssen Research & Development, Beerse, Belgium
| | - Angela Howes
- Janssen Research & Development, High Wycombe, UK
| | | | - Arnon P Kater
- Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, Netherlands
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32
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Fink A. Long-term efficacy of ibrutinib-venetoclax for first-line treatment in chronic lymphocytic leukaemia. Lancet Oncol 2023; 24:1294-1295. [PMID: 37944540 DOI: 10.1016/s1470-2045(23)00485-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Anna Fink
- Department I of Internal Medicine, University of Cologne, 50937 Cologne, Germany.
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33
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Baratè C, Sanna A, Benedetti E, Bocchia M, Capochiani E, Danesi R, Moretti S, Occhini U, Santini S, Galimberti S, Gozzetti A. Real-life diagnostic and therapeutic approach to CLL: a 2022 update from an expert panel in Tuscany. Clin Exp Med 2023; 23:4251-4264. [PMID: 37979127 DOI: 10.1007/s10238-023-01244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
A panel of chronic lymphocytic leukemia (CLL) experts from Tuscany propose a real-life diagnostic and therapeutic approach CLL that considers the role of genomic and somatic prognostic factors in risk stratification and treatment decisions. Safety and efficacy of new agents has been demonstrated now not only in clinical trials but also in many real-world series. The BTK inhibitors, ibrutinib and acalabrutinib, and BH3 mimetic venetoclax are now indicated as first-line therapy and chemoimmunotherapy can be spared to the majority of CLL patients, thus preventing unnecessary hematological and non-hematological toxicity and second primary tumors. For treatment, FISH for 17 p and P53 mutational status are essential. IGHV mutation can be done at diagnosis or before treatment. Echography is the gold standard radiological investigation in CLL, at both diagnosis and response evaluation. Chemotherapy is virtually abandoned. Age, genetic risk, and patient comorbidities have to be carefully evaluated for treatment decision. With the availability of different drugs, there is a need for a uniform and shared approach in daily therapeutic choice. The proposed approach is based on current evidence and guidelines as well as results from clinical trials and daily clinical experience.
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Affiliation(s)
- Claudia Baratè
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Edoardo Benedetti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), Pisa, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Enrico Capochiani
- Hematology Unit, Department of Internal Medicine, Toscana Nord Ovest, Leghorn, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | | | | | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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34
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Innocenti I, Fresa A, Tomasso A, Tarnani M, De Padua L, Benintende G, Pasquale R, Galli E, Morelli F, Giannarelli D, Autore F, Laurenti L. Treatment Sequencing and Outcome of Chronic Lymphocytic Leukemia Patients Treated at Fondazione Policlinico Universitario Agostino Gemelli IRCCS: A Thirty-Year Single-Center Experience. Cancers (Basel) 2023; 15:5592. [PMID: 38067296 PMCID: PMC10705134 DOI: 10.3390/cancers15235592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 10/16/2024] Open
Abstract
BACKGROUND This monocentric retrospective study describes the treatment patterns and outcomes of chronic lymphocytic leukemia (CLL) patients. METHODS Adult CLL patients treated between 1992 and 2022 were included. The time to next treatment (TTNT) was defined as the time from the treatment's start to the start of a subsequent therapy or death. The time to next treatment failure or death (TTNTF) was defined as the time from treatment discontinuation to the discontinuation of a subsequent therapy or death. RESULTS Of 637 registered patients, 318 (49.9%) received treatment. We evaluated 157 cBTKi-exposed, 34 BCL2i-exposed cBTKi-naïve, and 26 double-exposed patients. The five-year TTNT values in the cBTKi-exposed patients were 80% (median NR), 40% (median 40 months), and 21% (median 24 months) months in the first line (1L), second line (2L), and beyond the second line (>2L), respectively (p < 0.0001). The five-year TTNT values in the BCL2i-exposed patients were 83% (median NR), 72% (median NR), 12% (median 28 months) in the 1L, 2L, and >2L, respectively (p = 0.185). The median TTNTF was 9 months (range 1-87) after cBTKi and 17 months (range 8-49) after both a cBTKi and BCL2i. CONCLUSIONS This study suggests that, in CLL patients, the earlier we used targeted therapies, the better was the outcome obtained. Nonetheless, the poor outcomes in the advanced lines of therapy highlight the need for more effective treatments.
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Affiliation(s)
- Idanna Innocenti
- Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (I.I.); (A.F.); (E.G.); (F.A.)
| | - Alberto Fresa
- Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (I.I.); (A.F.); (E.G.); (F.A.)
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Annamaria Tomasso
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Michela Tarnani
- Hematology Department, Ospedale Belcolle, 01100 Viterbo, Italy;
| | - Laura De Padua
- Hematology Department, Fabrizio Spaziani Hospital, 03100 Frosinone, Italy;
| | - Giulia Benintende
- Department of Medicine 5, Haematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Universitätsklinikum, 91054 Erlangen, Germany;
| | - Raffaella Pasquale
- Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), SOC Clinica Ematologia, 33100 Udine, Italy;
| | - Eugenio Galli
- Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (I.I.); (A.F.); (E.G.); (F.A.)
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University of Sacred Heart, 00168 Rome, Italy;
| | - Francesca Morelli
- Department of Hematology, Universitá degli Studi di Firenze, 50121 Florence, Italy;
| | - Diana Giannarelli
- Facility of Epidemiology and Biostatistics, GSTeP, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Francesco Autore
- Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (I.I.); (A.F.); (E.G.); (F.A.)
| | - Luca Laurenti
- Department of Diagnostic Imaging, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (I.I.); (A.F.); (E.G.); (F.A.)
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University of Sacred Heart, 00168 Rome, Italy;
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35
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Chong SJF, Zhu F, Dashevsky O, Mizuno R, Lai JX, Hackett L, Ryan CE, Collins MC, Iorgulescu JB, Guièze R, Penailillo J, Carrasco R, Hwang YC, Muñoz DP, Bouhaddou M, Lim YC, Wu CJ, Allan JN, Furman RR, Goh BC, Pervaiz S, Coppé JP, Mitsiades CS, Davids MS. Hyperphosphorylation of BCL-2 family proteins underlies functional resistance to venetoclax in lymphoid malignancies. J Clin Invest 2023; 133:e170169. [PMID: 37751299 PMCID: PMC10645378 DOI: 10.1172/jci170169] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023] Open
Abstract
The B cell leukemia/lymphoma 2 (BCL-2) inhibitor venetoclax is effective in chronic lymphocytic leukemia (CLL); however, resistance may develop over time. Other lymphoid malignancies such as diffuse large B cell lymphoma (DLBCL) are frequently intrinsically resistant to venetoclax. Although genomic resistance mechanisms such as BCL2 mutations have been described, this probably only explains a subset of resistant cases. Using 2 complementary functional precision medicine techniques - BH3 profiling and high-throughput kinase activity mapping - we found that hyperphosphorylation of BCL-2 family proteins, including antiapoptotic myeloid leukemia 1 (MCL-1) and BCL-2 and proapoptotic BCL-2 agonist of cell death (BAD) and BCL-2 associated X, apoptosis regulator (BAX), underlies functional mechanisms of both intrinsic and acquired resistance to venetoclax in CLL and DLBCL. Additionally, we provide evidence that antiapoptotic BCL-2 family protein phosphorylation altered the apoptotic protein interactome, thereby changing the profile of functional dependence on these prosurvival proteins. Targeting BCL-2 family protein phosphorylation with phosphatase-activating drugs rewired these dependencies, thus restoring sensitivity to venetoclax in a panel of venetoclax-resistant lymphoid cell lines, a resistant mouse model, and in paired patient samples before venetoclax treatment and at the time of progression.
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MESH Headings
- Mice
- Animals
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Drug Resistance, Neoplasm/genetics
- Proto-Oncogene Proteins c-bcl-2/genetics
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- bcl-X Protein/genetics
- Apoptosis Regulatory Proteins
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Cell Line, Tumor
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Apoptosis/genetics
- Myeloid Cell Leukemia Sequence 1 Protein/genetics
- Myeloid Cell Leukemia Sequence 1 Protein/metabolism
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Affiliation(s)
- Stephen Jun Fei Chong
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Fen Zhu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga Dashevsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Rin Mizuno
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Jolin X.H. Lai
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Liam Hackett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine E. Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary C. Collins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Bryan Iorgulescu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Romain Guièze
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Johany Penailillo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Ruben Carrasco
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Yeonjoo C. Hwang
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, California, USA
| | - Denise P. Muñoz
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, California, USA
| | - Mehdi Bouhaddou
- Department of Microbiology, Immunology and Molecular Genetics, UCLA, Los Angeles, California, USA
| | - Yaw Chyn Lim
- Cancer Science Institute, National University of Singapore, Singapore
| | - Catherine J. Wu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - John N. Allan
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Richard R. Furman
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, New York, USA
| | - Boon Cher Goh
- Cancer Science Institute, National University of Singapore, Singapore
| | - Shazib Pervaiz
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jean-Philippe Coppé
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, California, USA
| | - Constantine S. Mitsiades
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
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Chatzikonstantinou T, Scarfò L, Karakatsoulis G, Minga E, Chamou D, Iacoboni G, Kotaskova J, Demosthenous C, Smolej L, Mulligan S, Alcoceba M, Al-Shemari S, Aurran-Schleinitz T, Bacchiarri F, Bellido M, Bijou F, Calleja A, Medina A, Khan MA, Cassin R, Chatzileontiadou S, Collado R, Christian A, Davis Z, Dimou M, Donaldson D, Santos GD, Dreta B, Efstathopoulou M, El-Ashwah S, Enrico A, Fresa A, Galimberti S, Galitzia A, García-Serra R, Gimeno E, González-Gascón-y-Marín I, Gozzetti A, Guarente V, Guieze R, Gogia A, Gupta R, Harrop S, Hatzimichael E, Herishanu Y, Hernández-Rivas JÁ, Inchiappa L, Jaksic O, Janssen S, Kalicińska E, Kamel L, Karakus V, Kater AP, Kho B, Kislova M, Konstantinou E, Koren-Michowitz M, Kotsianidis I, Kreitman RJ, Labrador J, Lad D, Levin MD, Levy I, Longval T, Lopez-Garcia A, Marquet J, Martin-Rodríguez L, Maynadié M, Maslejova S, Mayor-Bastida C, Mihaljevic B, Milosevic I, Miras F, Moia R, Morawska M, Murru R, Nath UK, Navarro-Bailón A, Oliveira AC, Olivieri J, Oscier D, Panovska-Stavridis I, Papaioannou M, Papajík T, Kubova Z, Phumphukhieo P, Pierie C, Puiggros A, Rani L, Reda G, Rigolin GM, Ruchlemer R, Daniel de Deus Santos M, Schipani M, Schiwitza A, Shen Y, Simkovic M, Smirnova S, Abdelrahman Soliman DS, Spacek M, Tadmor T, Tomic K, Tse E, Vassilakopoulos T, Visentin A, Vitale C, von Tresckow J, Vrachiolias G, Vukovic V, Walewska R, Wasik-Szczepanek E, Xu Z, Yagci M, Yañez L, Yassin M, Zuchnicka J, Angelopoulou M, Antic D, Biderman B, Catherwood M, Claus R, Coscia M, Cuneo A, Demirkan F, Espinet B, Gaidano G, Kalashnikova OB, Laurenti L, Nikitin E, Pangalis GA, Panagiotidis P, Popov VM, Pospisilova S, Sportoletti P, Stavroyianni N, Tam C, Trentin L, Chatzidimitriou A, Bosch F, Doubek M, Ghia P, Stamatopoulos K. Other malignancies in the history of CLL: an international multicenter study conducted by ERIC, the European Research Initiative on CLL, in HARMONY. EClinicalMedicine 2023; 65:102307. [PMID: 38033506 PMCID: PMC10685149 DOI: 10.1016/j.eclinm.2023.102307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
Background Patients with chronic lymphocytic leukemia (CLL) have a higher risk of developing other malignancies (OMs) compared to the general population. However, the impact of CLL-related risk factors and CLL-directed treatment is still unclear and represents the focus of this work. Methods We conducted a retrospective international multicenter study to assess the incidence of OMs and detect potential risk factors in 19,705 patients with CLL, small lymphocytic lymphoma, or high-count CLL-like monoclonal B-cell lymphocytosis, diagnosed between 2000 and 2016. Data collection took place between October 2020 and March 2022. Findings In 129,254 years of follow-up after CLL diagnosis, 3513 OMs were diagnosed (27.2 OMs/1000 person-years). The most common hematological OMs were Richter transformation, myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Non-melanoma skin (NMSC) and prostate cancers were the most common solid tumors (STs).The only predictor for MDS and AML development was treatment with fludarabine and cyclophosphamide with/without rituximab (FC ± R) (OR = 3.7; 95% CI = 2.79-4.91; p < 0.001). STs were more frequent in males and patients with unmutated immunoglobulin heavy variable genes (OR = 1.77; 95% CI = 1.49-2.11; p < 0.001/OR = 1.89; 95% CI = 1.6-2.24; p < 0.001).CLL-directed treatment was associated with non-melanoma skin and prostate cancers (OR = 1.8; 95% CI = 1.36-2.41; p < 0.001/OR = 2.11; 95% CI = 1.12-3.97; p = 0.021). In contrast, breast cancers were more frequent in untreated patients (OR = 0.17; 95% CI = 0.08-0.33; p < 0.001).Patients with CLL and an OM had inferior overall survival (OS) than those without. AML and MDS conferred the worst OS (p < 0.001). Interpretation OMs in CLL impact on OS. Treatment for CLL increased the risk for AML/MDS, prostate cancer, and NMSC. FCR was associated with increased risk for AML/MDS. Funding AbbVie, and EU/EFPIAInnovative Medicines Initiative Joint Undertaking HARMONY grant n° 116026.
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Affiliation(s)
| | - Lydia Scarfò
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Georgios Karakatsoulis
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
- Department of Mathematics, University of Ioannina, Ioannina, Greece
| | - Eva Minga
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Dimitra Chamou
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Gloria Iacoboni
- Department of Haematology, University Hospital Vall d'Hebron, Autonomous University, Barcelona, Spain
| | - Jana Kotaskova
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Lukas Smolej
- 4th Department of Internal Medicine-Haematology, University Hospital and Faculty of Medicine, Hradec Králové, Czech Republic
| | | | - Miguel Alcoceba
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC (CB16/12/00233) and Cancer Research Centre (CIC-IBMCC, USAL-CSIC), Salamanca, Spain
| | - Salem Al-Shemari
- Faculty of Medicine, Department of Medicine, Kuwait University, Kuwait City, Kuwait
| | | | | | - Mar Bellido
- Hematology Department, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Anne Calleja
- Department of Hemato-Oncology, Institut Paoli Calmettes, Marseille, France
| | | | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Center/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Ramona Cassin
- Hematology Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | - Sofia Chatzileontiadou
- Hematology Unit, 1st Dept of Internal Medicine, AUTH, AHEPA Hospital, Thessaloniki, Greece
| | - Rosa Collado
- Servicio de Hematología, Consorcio Hospital General Universitario de Valencia, Fundación de Investigación Hospital General Universitario de Valencia, Valencia, Spain
| | - Amy Christian
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Zadie Davis
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Maria Dimou
- Department of Hematology and Bone Marrow Transplantation Unit, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - David Donaldson
- Clinical Haematology, Belfast City Hospital, Belfast, United Kingdom
| | | | - Barbara Dreta
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb, Zagreb, Croatia
| | - Maria Efstathopoulou
- Department of Haematology, Athens Medical Center-Psychikon Branch, Athens, Greece
| | | | | | - Alberto Fresa
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sara Galimberti
- Section of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Andrea Galitzia
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS "G. Brotzu", Cagliari, Italy
| | - Rocío García-Serra
- Servicio de Hematología, Consorcio Hospital General Universitario de Valencia, Fundación de Investigación Hospital General Universitario de Valencia, Valencia, Spain
| | - Eva Gimeno
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | | | | | - Valerio Guarente
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Romain Guieze
- Department of Hematology and Cell Therapy, Estaing University Hospital, Clermont-Ferrand, France
| | - Ajay Gogia
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ritu Gupta
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Sean Harrop
- Peter MacCallum Cancer Centre, St Vincent's Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Eleftheria Hatzimichael
- Faculty of Medicine, Department of Haematology, School of Health Sciences, University of Ioannina, Stavros Niarchos Avenue, Ioannina 45110, Greece
| | - Yair Herishanu
- Department of Hematology, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Luca Inchiappa
- Department of Hemato-Oncology, Institut Paoli Calmettes, Marseille, France
| | - Ozren Jaksic
- Department of Hematology, University Hospital Dubrava, Zagreb, Croatia
| | - Susanne Janssen
- Dept of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Elżbieta Kalicińska
- Department and Clinic of Hematology, Blood Neoplasms and Bone Marrow Transplantation Wroclaw Medical University, Wroclaw, Poland
| | - Laribi Kamel
- Department of Hematology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Arnon P. Kater
- Dept of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Bonnie Kho
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China
| | - Maria Kislova
- Department of Hematology, Oncology, and Chemotherapy, S. P. Botkin's City Hospital, Moscow, Russia
| | | | - Maya Koren-Michowitz
- Department of Hematology, Shamir Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ioannis Kotsianidis
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Robert J. Kreitman
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jorge Labrador
- Department of Hematology, Hospital Universitario de Burgos, Burgos, Spain
| | - Deepesh Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Ilana Levy
- Hematology, Bnai-Zion Medical Center, Haifa, Israel
| | - Thomas Longval
- Service d'Hématologie Oncologie, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Alberto Lopez-Garcia
- Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Juan Marquet
- Hematology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Lucia Martin-Rodríguez
- Department of Haematology, University Hospital Vall d'Hebron, Autonomous University, Barcelona, Spain
| | - Marc Maynadié
- Biological Haematology Department, Dijon Bourgogne University Hospital, Haematological Malignancies Registry, LNC UMR 1231, Dijon 21000, France
| | - Stanislava Maslejova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Biljana Mihaljevic
- Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Milosevic
- Faculty of Medicine, Clinical Centre of Vojvodina, University of Novi Sad, Novi Sad, Serbia
| | - Fatima Miras
- Hematology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Riccardo Moia
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Marta Morawska
- Experimental Hematooncology Department, Medical University of Lublin, Lublin, Poland
- Hematology Department, St. John's Cancer Center, Lublin, Poland
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS "G. Brotzu", Cagliari, Italy
| | - Uttam Kumar Nath
- Department of Medical Oncology & Hematology, All India Institute of Medical Sciences, Rishikesh, India
| | - Almudena Navarro-Bailón
- Department of Haematology, University Hospital of Salamanca (HUS-IBSAL), CIBERONC (CB16/12/00233) and Cancer Research Centre (CIC-IBMCC, USAL-CSIC), Salamanca, Spain
| | - Ana C. Oliveira
- Department of Clinical Hematology, ICO, Hospital Duran i Reynals, IDIBELL, Barcelona, Spain
| | | | - David Oscier
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Irina Panovska-Stavridis
- Medical Faculty, University Clinic of Hematology, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Maria Papaioannou
- Hematology Unit, 1st Dept of Internal Medicine, AUTH, AHEPA Hospital, Thessaloniki, Greece
| | - Tomas Papajík
- Faculty of Medicine and Dentistry, Department of Hemato-Oncology, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Zuzana Kubova
- Faculty of Medicine and Dentistry, Department of Hemato-Oncology, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | | | - Cheyenne Pierie
- Dept of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Anna Puiggros
- Molecular Cytogenetics Laboratory, Pathology Department, Hospital del Mar and Translational Research on Hematological Neoplasms Group, Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Lata Rani
- Laboratory Oncology Unit, Dr. B.R.A. IRCH, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Gianluigi Reda
- Hematology Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, Milan, Italy
| | | | - Rosa Ruchlemer
- Department of Hematology, Shaare-Zedek Medical Center, Affiliated with the Hebrew University Medical School, Jerusalem, Israel
| | | | - Mattia Schipani
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Annett Schiwitza
- Hematology and Oncology, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, Augsburg 86156, Germany
| | - Yandong Shen
- Royal North Shore Hospital, Sydney, NSW, Australia
| | - Martin Simkovic
- 4th Department of Internal Medicine-Haematology, University Hospital and Faculty of Medicine, Hradec Králové, Czech Republic
| | - Svetlana Smirnova
- Consultative Hematology Department with a Day Hospital for Intensive High-Dose Chemotherapy, National Medical Research Center for Hematology, Moscow, Russia
| | | | - Martin Spacek
- First Faculty of Medicine, 1st Department of Medicine - Hematology, Charles University and General Hospital in Prague, Czech Republic
| | - Tamar Tadmor
- Hematology, Bnai-Zion Medical Center, Haifa, Israel
| | - Kristina Tomic
- Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Eric Tse
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - George Vrachiolias
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vojin Vukovic
- Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Renata Walewska
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Ewa Wasik-Szczepanek
- Dept. Hematooncology and Bone Marrow Transplantation, Medical University in Lublin, Lublin, Poland
| | - Zhenshu Xu
- Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, China
| | - Munci Yagci
- Gazi University Medical Faculty, Ankara, Turkey
| | - Lucrecia Yañez
- Department of Hematology, University Hospital Marqués de Valdecilla, Santander, Spain
- Department of Hematological Malignancies and Stem Cell Transplantation, Research Institute of Marques de Valdecilla (IDIVAL), Santander, Spain
| | - Mohamed Yassin
- Hematology Section, Department of Medical Oncology, National Center for Cancer Care and Research, Doha, Qatar
| | - Jana Zuchnicka
- Department of Haematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Maria Angelopoulou
- Haematology, University of Athens, Laikon General Hospital, Athens, Greece
| | - Darko Antic
- Clinic for Hematology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bella Biderman
- Department of Molecular Hematology, National Medical Research Center for Hematology, Moscow, Russia
| | - Mark Catherwood
- Clinical Haematology, Belfast City Hospital, Belfast, United Kingdom
| | - Rainer Claus
- Pathology, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, Augsburg 86156, Germany
- Faculty of Medicine, Comprehensive Cancer Center Augsburg, University of Augsburg, Stenglinstrasse 2, Augsburg 86156, Germany
| | - Marta Coscia
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | | | - Fatih Demirkan
- Division of Hematology, Dokuz Eylul University, Izmir, Turkey
| | - Blanca Espinet
- Molecular Cytogenetics Laboratory, Pathology Department, Hospital del Mar and Translational Research on Hematological Neoplasms Group, Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Olga B. Kalashnikova
- Federal State Budgetary Educational Institution of Higher Education Academician I.P. Pavlov First St. Petersburg State Medical University of the Ministry of Healthcare of Russian Federation, St. Petersburg, Russia
| | - Luca Laurenti
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eugene Nikitin
- Department of Hematology, Oncology, and Chemotherapy, S. P. Botkin's City Hospital, Moscow, Russia
| | | | - Panagiotis Panagiotidis
- Department of Hematology and Bone Marrow Transplantation Unit, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Viola Maria Popov
- Hematology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Sarka Pospisilova
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Paolo Sportoletti
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Niki Stavroyianni
- Hematology Department and HCT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Constantine Tam
- Peter MacCallum Cancer Centre, St Vincent's Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, Padova, Italy
| | | | - Francesc Bosch
- Department of Haematology, University Hospital Vall d'Hebron, Autonomous University, Barcelona, Spain
| | - Michael Doubek
- Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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Katz OB, Yehudai-Ofir D, Zuckerman T. Cellular Therapy in Chronic Lymphocytic Leukemia: Have We Advanced in the Last Decade? Acta Haematol 2023; 147:99-112. [PMID: 37812926 DOI: 10.1159/000534341] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/26/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is a heterogeneous B-cell malignancy, affecting mainly older adults. Despite the recent introduction of multiple targeted agents, CLL remains an incurable disease. Cellular therapy is a promptly evolving area that has developed over the last decades from such standard of care as hematopoietic cell transplantation (HCT) to the novel treatment modalities employing genetically engineered immune cells. SUMMARY Tailoring the proper treatment for each patient is warranted and should take into account the disease biology, patient characteristics, and the available treatment modalities. Nowadays, the most broadly applied cellular therapies for CLL management are HCT and chimeric antigen receptor-T (CAR-T) cells. However, CAR-T cell therapy is currently not yet approved in CLL, and the appropriate sequencing for the administration of these agents remains to be clarified. KEY MESSAGES The current review will discuss various available cellular treatment options, their advances and limitations, as well as the optimal timing for the employment of such therapies in CLL patients.
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Affiliation(s)
- Ofrat Beyar Katz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Dana Yehudai-Ofir
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Nguyen-Khac F, Balogh Z, Chauzeix J, Veronese L, Chapiro E. Cytogenetics in the management of chronic lymphocytic leukemia: Guidelines from the Groupe Francophone de Cytogénétique Hématologique (GFCH). Curr Res Transl Med 2023; 71:103410. [PMID: 38039634 DOI: 10.1016/j.retram.2023.103410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/14/2023] [Indexed: 12/03/2023]
Abstract
Chromosomal abnormalities are frequent in chronic lymphocytic leukemia (CLL), and most have prognostic value. In addition to the four well-known abnormalities (13q, 11q and 17p deletions, and trisomy 12), other recurrent aberrations have been linked to the disease outcome and/or drug resistance. Moreover, the complex karyotype has recently emerged as a prognostic marker for patients undergoing immunochemotherapy or targeted therapies. Here, we describe the main chromosomal abnormalities identified in CLL and related disorders (small lymphocytic lymphoma and monoclonal B-cell lymphocytosis) by reviewing the most recent literature and discussing their detection and clinical impact. Lastly, we provide technical guidelines and a strategy for the cytogenetic assessment of CLL.
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Affiliation(s)
- Florence Nguyen-Khac
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm UMRS 1138, Drug Resistance in Hematological Malignancies Team, F-75006 Paris, France; Sorbonne Université, Paris, France; Service d'Hématologie Biologique, Bâtiment Pharmacie, 3e étage, Pitié-Salpêtrière/Charles Foix University Hospital, AP-HP, 83 Bd de l'Hôpital, Paris F-75013, France.
| | - Zsofia Balogh
- Département d'Innovation Thérapeutique et des Essais Précoces, Gustave Roussy, Villejuif, France
| | - Jasmine Chauzeix
- Service d'Hématologie biologique, CHU de Limoges - CRIBL, UMR CNRS 7276/INSERM 1262, Limoges, France
| | - Lauren Veronese
- Service de Cytogénétique Médicale, CHU Estaing, 1 place Lucie et Raymond Aubrac, Clermont-Ferrand 63003, France
| | - Elise Chapiro
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm UMRS 1138, Drug Resistance in Hematological Malignancies Team, F-75006 Paris, France; Sorbonne Université, Paris, France; Service d'Hématologie Biologique, Bâtiment Pharmacie, 3e étage, Pitié-Salpêtrière/Charles Foix University Hospital, AP-HP, 83 Bd de l'Hôpital, Paris F-75013, France
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Laurenti L, Scarfò L, Frustaci AM, Sanna A, Iannella E, Caira M, Finsinger P, Schifano S, Neri B, Molica S, Mauro FR. Real-world evidence on venetoclax in chronic lymphocytic leukemia: The Italian experience. Hematol Oncol 2023; 41:621-630. [PMID: 36680368 DOI: 10.1002/hon.3122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/11/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common form of adult leukemia in the western world. In Italy, venetoclax was approved for use in patients with CLL as monotherapy in 2017 and in combinations in 2019. As a result of this delayed approval, there are relatively few real-world studies from Italian clinical practice and much of the data are in heavily pretreated patients. We have collected the available studies in Italian routine practice. Three studies confirm the effectiveness and tolerability of this agent in patients with relapsed/refractory CLL and high-risk disease characteristics, many of whom had received prior B-cell receptor signaling treatment. Addition of rituximab to venetoclax produced more complete responses in patients with relapsed/refractory CLL, while higher disease burden and progression while receiving a prior Bruton's tyrosine kinase inhibitor were both associated with poorer outcomes in patients treated with venetoclax. Venetoclax was well-tolerated with low discontinuation rates. No studies of venetoclax plus obinutuzumab for the first-line treatment of patients with CLL were available due to the short time since approval in Italy. Several cohorts addressed the impact of COVID-19 on patient management and outcomes, suggesting that treated patients and those in clinical observation had similar rates of COVID-19-related hospital admission, intensive care unit admission, and mortality. Overall, the responses and tolerance to venetoclax observed in the Italian real-world setting confirm the tolerability and effectiveness of venetoclax regimens in high-risk patients.
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Affiliation(s)
- Luca Laurenti
- Diagnostic Imaging, Oncological Radiotherapy and Hematology, IRCCS Agostino Gemelli University Policlinic, Rome, Italy
| | - Lydia Scarfò
- Strategic Research Program on CLL, Division of Experimental Oncology, Università Vita Salute and IRCCS San Raffaele Hospital Milan, Milan, Italy
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Huber H, Tausch E, Schneider C, Edenhofer S, von Tresckow J, Robrecht S, Giza A, Zhang C, Fürstenau M, Dreger P, Ritgen M, Illmer T, Illert AL, Dürig J, Böttcher S, Niemann CU, Kneba M, Al-Sawaf O, Kreuzer KA, Fink AM, Fischer K, Döhner H, Hallek M, Eichhorst B, Stilgenbauer S. Final analysis of the CLL2-GIVe trial: obinutuzumab, ibrutinib, and venetoclax for untreated CLL with del(17p)/TP53mut. Blood 2023; 142:961-972. [PMID: 37363867 DOI: 10.1182/blood.2023020013] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
The final analysis of the open-label, multicenter phase 2 CLL2-GIVe trial shows response and tolerability of the triple combination of obinutuzumab, ibrutinib, and venetoclax (GIVe regimen) in 41 previously untreated patients with high-risk chronic lymphocytic leukemia (CLL) with del(17p) and/or TP53 mutation. Induction consisted of 6 cycles of GIVe; venetoclax and ibrutinib were continued up to cycle 12 as consolidation. Ibrutinib was given until cycle 15 or up to cycle 36 in patients not achieving a complete response and with detectable minimal residual disease. The primary end point was the complete remission rate at cycle 15, which was achieved at 58.5% (95% CI, 42.1-73.7; P < .001). The last patient reached the end of the study in January 2022. After a median observation time of 38.4 months (range, 3.7-44.9), the 36-month progression-free survival was 79.9%, and the 36-month overall survival was 92.6%. Only 6 patients continued ibrutinib maintenance. Adverse events of concern were neutropenia (48.8%, grade ≥3) and infections (19.5%, grade ≥3). Cardiovascular toxicity grade 3 occurred as atrial fibrillation at a rate of 2.4% between cycles 1 and 12, as well as hypertension (4.9%) between cycles 1 and 6. The incidence of adverse events of any grade and grade ≥3 was highest during induction and decreased over time. Progressive disease was observed in 7 patients between cycles 27 and 42. In conclusion, the CLL2-GIVe regimen is a promising fixed-duration, first-line treatment for patients with high-risk CLL with a manageable safety profile.
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Affiliation(s)
- Henriette Huber
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
- Medizinische Klinik III, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Eugen Tausch
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Christof Schneider
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Simone Edenhofer
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Julia von Tresckow
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Can Zhang
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Moritz Fürstenau
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Matthias Ritgen
- Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Thomas Illmer
- Group Practice for Hematology and Oncology, Dresden, Germany
| | - Anna Lena Illert
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Dürig
- Deptartment of Internal Medicine, St. Josef Krankenhaus Werden, University Medicine Essen, Essen, Germany
| | | | - Carsten U Niemann
- Department of Clinical Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Michael Kneba
- Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Hartmut Döhner
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Stephan Stilgenbauer
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
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41
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Anderson MA, Bennett R, Badoux X, Best G, Chia N, Cochrane T, Cull G, Crassini K, Harrup R, Jackson S, Kuss B, Lasica M, Lew TE, Marlton P, Opat S, Palfreyman E, Polizzotto MN, Ratnasingam S, Seymour JF, Soosapilla A, Talaulikar D, Tam CS, Weinkove R, Wight J, Mulligan SP. Chronic lymphocytic leukaemia Australasian consensus practice statement. Intern Med J 2023; 53:1678-1691. [PMID: 37743239 DOI: 10.1111/imj.16207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 07/30/2023] [Indexed: 09/26/2023]
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common haematological malignancy in Australia and New Zealand (ANZ). Considerable changes to diagnostic and management algorithms have occurred within the last decade. The availability of next-generation sequencing and measurable residual disease assessment by flow cytometry allow for advanced prognostication and response assessments. Novel therapies, including inhibitors of Bruton's tyrosine kinase (BTKi) and B-cell lymphoma 2 (BCL2) inhibitors, have transformed the treatment landscape for both treatment-naïve and relapsed/refractory disease, particularly for patients with high-risk genetic aberrations. Recommendations regarding appropriate supportive management continue to evolve, and special considerations are required for patients with CLL with respect to the global SARS-CoV-2 pandemic. The unique funding and treatment environments in Australasia highlight the need for specific local guidance with respect to the investigation and management of CLL. This consensus practice statement was developed by a broadly representative group of ANZ experts in CLL with endorsement by peak haematology bodies, with a view to providing this standardised guidance.
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Affiliation(s)
- Mary A Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rory Bennett
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Xavier Badoux
- St George Hospital, Sydney, New South Wales, Australia
| | - Giles Best
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Nicole Chia
- Genomic Diagnostics, Healius Pathology, Brisbane, Queensland, Australia
| | - Tara Cochrane
- Gold Coast University Hospital, Griffith University, Gold Coast, Queensland, Australia
| | - Gavin Cull
- Sir Charles Gairdner Hospital, PathWest Laboratory Medicine and University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Crassini
- Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Rosemary Harrup
- Cancer and Blood Services Royal Hobart Hospital, Hobart, Tasmania, Australia
- Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharon Jackson
- Te Whatu Ora health New Zealand Counties Manukau, Auckland, New Zealand
| | - Bryone Kuss
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Masa Lasica
- St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Thomas E Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Stephen Opat
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Emma Palfreyman
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Mark N Polizzotto
- Department of Clinical Haematology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Clinical Hub for Interventional Research, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sumita Ratnasingam
- St John of God Hospital Geelong, Geelong, Victoria, Australia
- University Hospital Geelong, Geelong, Victoria, Australia
- School of Medicine, Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
| | - John F Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Asha Soosapilla
- Flow Cytometry, Healius Pathology, Sydney, New South Wales, Australia
| | - Dipti Talaulikar
- Department of Diagnostic Genomics, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Department of Haematology, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Constantine S Tam
- Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Robert Weinkove
- Te Rerenga Ora Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Joel Wight
- Department of Haematology and Bone Marrow Transplantation, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, School of Medicine, Townsville, Queensland, Australia
| | - Stephen P Mulligan
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Healius Pathology, Sydney, New South Wales, Australia
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43
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Visentin A, Mauro FR, Scarfò L, Gentile M, Farina L, Reda G, Ferrarini I, Proietti G, Derenzini E, Cibien F, Vitale C, Sanna A, Pietrasanta D, Marchetti M, Murru R, Rigolin GM, Sportoletti P, Trimarco V, Cavarretta CA, Angotzi F, Cellini A, Ruocco V, Zatta I, Laurenti L, Molica S, Coscia M, Ghia P, Foà R, Cuneo A, Trentin L. Continuous venetoclax in treatment-naive TP53 disrupted patients with chronic lymphocytic leukemia: A chronic lymphocytic leukemia campus study. Am J Hematol 2023; 98:E237-E240. [PMID: 37382471 DOI: 10.1002/ajh.27009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Lydia Scarfò
- Strategic Research Program on CLL, Università Vita-salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera of Cosenza, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Lucia Farina
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | - Isacco Ferrarini
- Department of Engineering for Innovation Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Giulia Proietti
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Enrico Derenzini
- Divisions of Haemato-oncology, Haematology Programme, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Candida Vitale
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, AOU Careggi, Florence, Italy
| | - Daniela Pietrasanta
- Division of Hematology, A.O. SS Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Monia Marchetti
- Division of Hematology, A.O. SS Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco, ARNAS G. Brotzu, Cagliari, Italy
| | - Gian Matteo Rigolin
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Paolo Sportoletti
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Valentina Trimarco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Chiara Adele Cavarretta
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesco Angotzi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alessandro Cellini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valeria Ruocco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ivan Zatta
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Laurenti
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | | | - Marta Coscia
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Ghia
- Strategic Research Program on CLL, Università Vita-salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
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44
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Michallet AS, Letestu R, Le Garff-Tavernier M, Campos L, Ticchioni M, Dilhuydy MS, Morisset S, Rouille V, Mahé B, Laribi K, Villemagne B, Ferrant E, Tournilhac O, Delmer A, Molina L, Leblond V, Tomowiak C, de Guibert S, Orsini-Piocelle F, Banos A, Carassou P, Cartron G, Fornecker LM, Ysebaert L, Dartigeas C, Truchan-Graczyk M, Vilque JP, Schleinitz TA, Cymbalista F, Leprêtre S, Lévy V, Nguyen-Khac F, Feugier P. A fixed-duration immunochemotherapy approach in CLL: 5.5-year results from the phase 2 ICLL-07 FILO trial. Blood Adv 2023; 7:3936-3945. [PMID: 37026799 PMCID: PMC10410135 DOI: 10.1182/bloodadvances.2022009594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023] Open
Abstract
In previously untreated, medically fit patients with chronic lymphocytic leukemia (CLL), research is focused on developing fixed-duration strategies to improve long-term outcomes while sparing patients from serious toxicities. The ICLL-07 trial evaluated a fixed-duration (15-month) immunochemotherapy approach in which after obinutuzumab-ibrutinib induction for 9 months, patients (n = 10) in complete remission (CR) with bone marrow (BM) measurable residual disease (MRD) <0.01% continued only ibrutinib 420 mg/day for 6 additional months (I arm), whereas the majority (n = 115) received up to 4 cycles of fludarabine/cyclophosphamide-obinutuzumab 1000 mg alongside the ibrutinib (I-FCG arm). Primary analysis at month 16 showed that 84 of 135 (62.2%) patients enrolled achieved CR with a BM MRD <0.01%. Here, we report follow-up at median 63 months. Peripheral blood (PB) MRD was assessed 6 monthly beyond the end of treatment using a highly sensitive (10-6) flow cytometry technique. In the I-FCG arm, the PB MRD <0.01% rate (low-level positive <0.01% or undetectable with limit of detection ≤10-4) in evaluable patients was still 92.5% (74/80) at month 40 and 80.6% (50/62) at month 64. No differences in the PB MRD status were apparent per to the IGHV mutational status. In the overall population, 4-year progression-free and overall survival rates were 95.5% and 96.2%, respectively. Twelve deaths occurred overall. Fourteen serious adverse events occurred beyond the end of treatment. Thus, our fixed-duration immunochemotherapy approach produced deep and sustained PB MRD responses, high survival rates, and low long-term toxicity. A randomized trial is needed to compare our immunochemotherapy approach with a chemotherapy-free strategy. This trial was registered at www.clinicaltrials.gov as #NCT02666898.
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Affiliation(s)
| | - Rémi Letestu
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
| | | | - Lydia Campos
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
| | | | | | | | - Valérie Rouille
- Department of Hematology, CHU Montpellier, Montpellier, France
| | - Béatrice Mahé
- Department of Hematology, Nantes University Hospital, Nantes, France
| | - Kamel Laribi
- Department of Hematology, CH Le Mans, Le Mans, France
| | | | - Emmanuelle Ferrant
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
| | - Olivier Tournilhac
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
| | - Alain Delmer
- Department of Hematology, CHU Reims, Reims, France
| | - Lysiane Molina
- Department of Hematology, CHU Grenoble, La Tronche, France
| | - Véronique Leblond
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | | | | | | | - Anne Banos
- Department of Hematology, CH Côte Basque, Bayonne, France
| | | | - Guillaume Cartron
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
| | | | - Loic Ysebaert
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | | | | | - Jean-Pierre Vilque
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
| | | | | | - Stéphane Leprêtre
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
| | - Vincent Lévy
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
| | | | - Pierre Feugier
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
| | - French Innovative Leukemia Organization (FILO) CLL group
- Department of Hematology, Centre Léon Bérard, Lyon, France
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
- Department of Hematology Biology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
- Department of Immunology, CHU Nice, Nice, France
- Department of Hematology, CHU Bordeaux, Pessac, France
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Nantes University Hospital, Nantes, France
- Department of Hematology, CH Le Mans, Le Mans, France
- Department of Hematology, CHD Vendée, La Roche-sur-Yon, France
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
- Department of Hematology, CHU Reims, Reims, France
- Department of Hematology, CHU Grenoble, La Tronche, France
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology, CHU Poitiers, Poitiers, France
- Department of Hematology, CHU Rennes, Rennes, France
- Hematology Service, CH Annecy, Annecy, France
- Department of Hematology, CH Côte Basque, Bayonne, France
- Department of Hematology, CH Metz, Metz, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
- Department of Hematology, Strasbourg University Hospital, Strasbourg, France
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
- Department of Hematology, CHU Tours, Hôpital Bretonneau, Tours, France
- Department of Hematology, CHU Angers, Angers, France
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
- Department of Hematology, Institut Paoli Calmettes, Marseille, Marseille France
- Department of Hematology, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
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45
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Mulligan SP. Karyotype and outcome in CLL. Blood 2023; 142:402-404. [PMID: 37535371 DOI: 10.1182/blood.2023020769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
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46
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Moia R, Dondolin R, De Propris MS, Talotta D, Mouhssine S, Perutelli F, Reda G, Mattiello V, Rigolin GM, Motta M, Olivieri J, Fanin R, Perbellini O, Ferrarini I, Mauro FR, Del Giudice I, Laurenti L, Tomasso A, Gentile M, Frustaci AM, Tedeschi A, Gozzetti A, Stelitano C, Visco C, Moreno C, Forconi F, Marasca R, Coscia M, Rossi D, Foà R, Gaidano G. Long-term benefit of IGHV mutated patients in a real-life multicenter cohort of FCR-treated chronic lymphocytic leukemia. Hematol Oncol 2023; 41:567-570. [PMID: 36190298 DOI: 10.1002/hon.3080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Riccardo Dondolin
- Division of Hematology, Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | | | - Donatella Talotta
- Division of Hematology, Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Samir Mouhssine
- Division of Hematology, Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Francesca Perutelli
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Veronica Mattiello
- Hematology Unit, Fondazione IRCCS Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gian Matteo Rigolin
- Department of Medical Sciences, Hematology Section, AOU Arcispedale S Anna, University of Ferrara, Ferrara, Italy
| | | | - Jacopo Olivieri
- Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), SOC Clinica Ematologica, Udine, Italy
| | - Renato Fanin
- Azienda Sanitaria Universitaria Friuli Centrale (ASU FC), SOC Clinica Ematologica, Udine, Italy
| | - Omar Perbellini
- Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
| | - Isacco Ferrarini
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Luca Laurenti
- Department of Hematology, Catholic University Hospital A. Gemelli, Rome, Italy
| | - Annamaria Tomasso
- Department of Hematology, Catholic University Hospital A. Gemelli, Rome, Italy
| | | | - Anna Maria Frustaci
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Caterina Stelitano
- U.O.C. Ematologia, Grande Ospedale Metropolitano Bianchi-Melacrino-Morelli, Reggio Di Calabria, Italy
| | - Carlo Visco
- Department of Medicine, Section of Haematology, University of Verona, Verona, Italy
| | - Carol Moreno
- Hospital de La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | | | - Roberto Marasca
- Department of Medical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Marta Coscia
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Davide Rossi
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
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47
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Nguyen PC, Nguyen V, Baldwin K, Kankanige Y, Blombery P, Came N, Westerman DA. Computational flow cytometry provides accurate assessment of measurable residual disease in chronic lymphocytic leukaemia. Br J Haematol 2023; 202:760-770. [PMID: 37052611 DOI: 10.1111/bjh.18802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
Undetectable measurable residual disease (MRD) is associated with favourable clinical outcomes in chronic lymphocytic leukaemia (CLL). While assessment is commonly performed using multiparameter flow cytometry (MFC), this approach is associated with limitations including user bias and expertise that may not be widely available. Implementation of unsupervised clustering algorithms in the laboratory can address these limitations and have not been previously reported in a systematic quantitative manner. We developed a computational pipeline to assess CLL MRD using FlowSOM. In the training step, a self-organising map was generated with nodes representing the full breadth of normal immature and mature B cells along with disease immunophenotypes. This map was used to detect MRD in multiple validation cohorts containing a total of 456 samples. This included an evaluation of atypical CLL cases and samples collected from two different laboratories. Computational MRD showed high correlation with expert analysis (Pearson's r > 0.99 for typical CLL). Binary classification of typical CLL samples as either MRD positive or negative demonstrated high concordance (>98%). Interestingly, computational MRD detected disease in a small number of atypical CLL cases in which MRD was not detected by expert analysis. These results demonstrate the feasibility and value of automated MFC analysis in a diagnostic laboratory.
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Affiliation(s)
- Phillip C Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vuong Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Kylie Baldwin
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Yamuna Kankanige
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Piers Blombery
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Neil Came
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - David A Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Urso A, Cavazzini F, Ballardini MP, Gambara S, Consolo S, Rigolin GM, Cuneo A. First-Line Treatment of Older Patients with CLL: A New Approach in the Chemo-Free Era. Cancers (Basel) 2023; 15:3859. [PMID: 37568676 PMCID: PMC10417156 DOI: 10.3390/cancers15153859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL2 inhibitor venetoclax, with or without the anti-CD20 monoclonal antibody Obinutuzumab, represent the preferred options for the first-line therapy of CLL because they are more effective and may improve quality of life. However, patient inclusion criteria are heterogeneous across trials designed for older patients, and the identification of CLL-specific parameters identifying unfit patients at risk of developing drug-specific adverse events is required to guide treatment choice. Due to inclusion/exclusion criteria in trials, higher discontinuation rates with BTKi were reported in real-world studies, and registry analyses provided useful information on factors predicting earlier discontinuation in a real-world setting. Though targeted agents were shown to be cost-effective treatments in high-income countries, the out-of-pocket expenses may limit accessibility to these drugs, and the overall expenditure for new drugs in CLL is projected to increase substantially, posing an issue for sustainability. This being said, the choice of a finite-duration treatment based on venetoclax-containing regimens or treatment until progression with BTKi is today possible in high-income countries, and the therapy choice drivers are represented by coexisting medical conditions rather than age, patient expectations, logistics, and sustainability.
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Affiliation(s)
| | | | | | | | | | | | - Antonio Cuneo
- Hematology Unit, University of Ferrara, 44121 Ferrara, Italy (F.C.); (M.P.B.); (S.C.)
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49
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Rogers KA. A CAPTIVATEing Analysis for Higher-Risk CLL. Clin Cancer Res 2023; 29:2561-2562. [PMID: 37289004 PMCID: PMC10443675 DOI: 10.1158/1078-0432.ccr-23-0807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 06/09/2023]
Abstract
In an exploratory analysis of the phase II CAPTIVATE study, previously untreated patients with chronic lymphocytic leukemia with a higher-risk feature of immune globulin heavy chain variable (IGHV) unmutated status, del(17p), and/or TP53 mutation had similar efficacy and safety outcomes compared with patients without a higher-risk feature when treated with fixed-duration ibrutinib and venetoclax. See related article by Allan et al., p. 2593.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Piperidines
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Mutation
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50
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Bennett R, Anderson MA, Seymour JF. Unresolved questions in selection of therapies for treatment-naïve chronic lymphocytic leukemia. J Hematol Oncol 2023; 16:72. [PMID: 37422670 PMCID: PMC10329329 DOI: 10.1186/s13045-023-01469-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The treatment landscape for chronic lymphocytic leukemia (CLL) continues to undergo considerable evolution. Optimal selection of initial therapy from multiple effective options provides a major challenge for clinicians, who need to consider both disease and patient factors in conjunction with a view to sequencing available therapies in event of disease relapse. REVIEW We explore the most topical clinically relevant unresolved questions through discussion of important available pertinent literature and propose expert opinion based on these data. (1) Shrinking role of chemoimmunotherapy (CIT); while novel therapies are generally superior, we highlight the utility of FCR for IGHV-mutated CLL. (2) Choosing between inhibitors of Bruton's tyrosine kinase (BTKi); while efficacy between agents is likely similar there are important differences in toxicity profiles, including the incidence of cardiac arrhythmia and hypertension. (3) BTKi with or without anti-CD20 monoclonal antibodies (mAb); while obinutuzumab-acalabrutinib (AO) may confer superior progression-free survival to acalabrutinib (Acala), this is not true of rituximab (Ritux) to ibrutinib (Ib)-we highlight that potential for increased side effects should be carefully considered. (4) Continuous BTKi versus time-limited venetoclax-obinutuzumab (VenO); we propose that venetoclax (Ven)-based therapy is generally preferable to BTKi with exception of TP53 aberrant disease. (5) BTKi-Ven versus VenO as preferred time-limited therapy; we discuss comparable efficacies and the concerns about simultaneous 1L exposure to both BTKi and Ven drug classes. (6) Utility of triplet therapy (BTKi-Ven-antiCD20 mAb) versus VenO; similar rates of complete response are observed yet with greater potential for adverse events. (7) Optimal therapy for TP53 aberrant CLL; while limited data are available, there are likely effective novel therapy combinations for TP53 aberrant disease including BTKi, BTKi-Ven ± antiCD20 mAb. CONCLUSION Frontline therapy for CLL should be selected based on efficacy considering the patient specific biologic profile of their disease and potential toxicities, considering patient comorbidities and preferences. With the present paradigm of sequencing effective agents, 1L combinations of novel therapies should be used with caution in view of potential adverse events and theoretical resistance mechanism concerns in the absence of compelling randomized data to support augmented efficacy.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, 1G, Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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