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Abstract
Abstract
The B-cell leukemia/lymphoma-2 (BCL-2) family of proteins governs the intrinsic pathway of mitochondrial apoptosis. Dysregulation of BCL-2 has long been known to be a crucial part of the pathophysiology of B-cell lymphomas; however, several early attempts to target this pathway therapeutically were unsuccessful because of toxicity, lack of efficacy, or both. Recently, a highly potent and selective oral BCL-2 antagonist, venetoclax, was approved in chronic lymphocytic leukemia, where it has proven to be highly active, even in patients with high-risk del(17p) disease. Venetoclax has also demonstrated efficacy in other B-cell non-Hodgkin lymphoma subtypes, in particular mantle cell lymphoma and follicular lymphoma. Here, I review the history of targeting BCL-2 in B-cell lymphomas, and I discuss recent data on venetoclax used as monotherapy and in combination with monoclonal antibodies, chemotherapy, and other novel agents. I also discuss how genomic and functional approaches such as BH3 profiling may allow us to prioritize novel-agent combinations for further study in clinical trials. These approaches may also help us to understand resistance mechanisms to BCL-2–selective therapy and how to overcome resistance. Finally, I provide my perspective on how to move BCL-2–directed therapies forward toward a goal of developing well-tolerated, time-limited combination regimens with curative potential for patients with B-cell lymphomas.
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502
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Promising efficacy and acceptable safety of venetoclax plus bortezomib and dexamethasone in relapsed/refractory MM. Blood 2017; 130:2392-2400. [PMID: 28847998 DOI: 10.1182/blood-2017-06-788323] [Citation(s) in RCA: 199] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/21/2017] [Indexed: 12/20/2022] Open
Abstract
The antiapoptotic proteins BCL-2 and myeloid cell leukemia sequence 1 (MCL-1) promote multiple myeloma (MM) cell survival. Venetoclax is a selective, orally bioavailable small-molecule BCL-2 inhibitor; bortezomib can indirectly inhibit MCL-1. In preclinical studies, venetoclax enhanced bortezomib activity, suggesting that cotargeting of BCL-2 and MCL-1 could be an effective treatment strategy in myeloma. This phase 1b trial studied patients with relapsed/refractory MM receiving daily venetoclax (50-1200 mg per designated dose cohort; 800 mg in safety expansion) in combination with bortezomib and dexamethasone. A total of 66 patients were enrolled (54 in the dose-escalation cohorts and 12 in the safety expansion). Patients had received a median of 3 prior therapies (range, 1-13); 26 (39%) were refractory to prior bortezomib and 35 (53%) to lenalidomide; 39 (59%) had prior stem cell transplant. The combination was generally well tolerated, and common adverse events included mild gastrointestinal toxicities (diarrhea [46%], constipation [41%], and nausea [38%]) and grade 3/4 cytopenias (thrombocytopenia [29%] and anemia [15%]). The overall response rate (ORR) was 67% (44/66); 42% achieved very good partial response or better (≥VGPR). Median time to progression and duration of response were 9.5 and 9.7 months, respectively. ORR of 97% and ≥VGPR 73% were seen in patients not refractory to bortezomib who had 1 to 3 prior therapies. Patients with high BCL2 expression had a higher ORR (94% [17/18]) than patients with low BCL2 expression (59% [16/27]). This novel combination of venetoclax with bortezomib and dexamethasone has an acceptable safety profile and promising efficacy in patients with relapsed/refractory MM. This trial was registered at www.clinicaltrials.gov as #NCT01794507.
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503
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Abstract
OPINION STATEMENT A number of new treatment options have recently emerged for chronic lymphocytic leukemia (CLL) patients, including the Bruton's tyrosine kinase (BTK) inhibitor ibrutinib, phosphatidylinositol-3-kinase (PI3K) delta isoform inhibitor idelalisib combined with rituximab, the Bcl-2 antagonist venetoclax, and the new anti-CD20 antibodies obinutuzumab and ofatumumab. Most of these agents are already included into treatment algorithms defined by international practice guidelines, but more clinical investigations are needed to answer still remaining questions. Ibrutinib was proven as a primary choice for patients with the TP53 gene deletion/mutation, who otherwise have no active treatment available. Idelalisib with rituximab is also an active therapy, but due to increased risk of serious infections, its use in first-line treatment is limited to patients for whom ibrutinib is not an option. A new indication for ibrutinib was recently approved for older patients with comorbidities, as an alternative to the already existing indication for chlorambucil with obinutuzumab. The use of kinase inhibitors is already well established in recurrent/refractory disease. Immunochemotherapy with fludarabine, cyclophosphamide, rituximab (FCR) remains a major first-line option for many CLL patients without the TP53 gene deletion/mutation, and who have no significant comorbidities or history of infections, and is particularly effective in patients with favorable features including mutated IGHV status. There are a number of issues regarding novel therapies for CLL that need further investigation such as optimum duration of treatment with kinase inhibitors, appropriate sequencing of novel agents, mechanisms of resistance to inhibitors and response to class switching after treatment failure, along with the potential role of combinations of targeted agents.
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504
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Abstract
OPINION STATEMENT The front-line management of patients with chronic lymphocytic leukemia (CLL) has evolved significantly in recent years due to introduction of novel, targeted agents. Upon CLL diagnosis, physicians should determine whether treatment or careful observation is indicated. Once treatment is required, choice of therapy should be based on the age and fitness of the patient and the distinct molecular profile of their disease. As multiple novel agents are in various stages of development, all patients regardless of their age, fitness, and disease risk should be evaluated for clinical trial participation before initiating any front-line therapy. If no clinical trial is available, we provide our recommendations for front-line treatment of CLL patients. Healthy, young patients with low-risk disease (mutated IgVH, del (13q)) should be offered fludarabine, chlorambucil, and rituximab (FCR), while similar patients with high-risk disease (unmutated IgVH, del (17p), del (11q), and complex karyotype) should be considered for ibrutinib therapy. For those young, fit patients with high-risk disease and a contraindication to ibrutinib, FCR, or high-dose methylprednisolone and rituximab are options. In regard to older, unfit patients, a careful assessment of their fitness and ability to tolerate treatment should be undertaken before starting therapy. Those who have poor performance and multiple medical comorbidities should be considered for palliative care alone. However, those who are fit enough for treatment can be offered ibrutinib. If there is a contraindication to ibrutinib, they can be separated into low- and high-risk molecular groups. For the low-risk patients, bendamustine and rituximab or obinutuzumab and chlorambucil can be considered. For the high-risk patients, treatment with rituximab and lenalidomide is an option. Herein, we provide an evidence-based front-line treatment algorithm for CLL patients based upon fitness and molecular risk.
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505
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Allogeneic hematopoietic cell transplantation for high-risk CLL: 10-year follow-up of the GCLLSG CLL3X trial. Blood 2017; 130:1477-1480. [PMID: 28716861 DOI: 10.1182/blood-2017-04-775841] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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506
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Turtle CJ, Hay KA, Hanafi LA, Li D, Cherian S, Chen X, Wood B, Lozanski A, Byrd JC, Heimfeld S, Riddell SR, Maloney DG. Durable Molecular Remissions in Chronic Lymphocytic Leukemia Treated With CD19-Specific Chimeric Antigen Receptor-Modified T Cells After Failure of Ibrutinib. J Clin Oncol 2017; 35:3010-3020. [PMID: 28715249 DOI: 10.1200/jco.2017.72.8519] [Citation(s) in RCA: 482] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Purpose We evaluated the safety and feasibility of anti-CD19 chimeric antigen receptor-modified T (CAR-T) cell therapy in patients with chronic lymphocytic leukemia (CLL) who had previously received ibrutinib. Methods Twenty-four patients with CLL received lymphodepleting chemotherapy and anti-CD19 CAR-T cells at one of three dose levels (2 × 105, 2 × 106, or 2 × 107 CAR-T cells/kg). Nineteen patients experienced disease progression while receiving ibrutinib, three were ibrutinib intolerant, and two did not experience progression while receiving ibrutinib. Six patients were venetoclax refractory, and 23 had a complex karyotype and/or 17p deletion. Results Four weeks after CAR-T cell infusion, the overall response rate (complete response [CR] and/or partial response [PR]) by International Workshop on Chronic Lymphocytic Leukemia (IWCLL) criteria was 71% (17 of 24). Twenty patients (83%) developed cytokine release syndrome, and eight (33%) developed neurotoxicity, which was reversible in all but one patient with a fatal outcome. Twenty of 24 patients received cyclophosphamide and fludarabine lymphodepletion and CD19 CAR-T cells at or below the maximum tolerated dose (≤ 2 × 106 CAR-T cells/kg). In 19 of these patients who were restaged, the overall response rate by IWCLL imaging criteria 4 weeks after infusion was 74% (CR, 4/19, 21%; PR, 10/19, 53%), and 15/17 patients (88%) with marrow disease before CAR-T cells had no disease by flow cytometry after CAR-T cells. Twelve of these patients underwent deep IGH sequencing, and seven (58%) had no malignant IGH sequences detected in marrow. Absence of the malignant IGH clone in marrow of patients with CLL who responded by IWCLL criteria was associated with 100% progression-free survival and overall survival (median 6.6 months follow-up) after CAR-T cell immunotherapy. The progression-free survival was similar in patients with lymph node PR or CR by IWCLL criteria. Conclusion CD19 CAR-T cells are highly effective in high-risk patients with CLL after they experience treatment failure with ibrutinib therapy.
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Affiliation(s)
- Cameron J Turtle
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Kevin A Hay
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Laïla-Aïcha Hanafi
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Daniel Li
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Sindhu Cherian
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Xueyan Chen
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Brent Wood
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Arletta Lozanski
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - John C Byrd
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Shelly Heimfeld
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - Stanley R Riddell
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
| | - David G Maloney
- Cameron J. Turtle, Kevin A. Hay, Laïla-Aïcha Hanafi, Shelly Heimfeld, Stanley R. Riddell, and David G. Maloney, Fred Hutchinson Cancer Research Center; Cameron J. Turtle, Sindhu Cherian, Xueyan Chen, Brent Wood, Stanley R. Riddell, and David G. Maloney, University of Washington; Daniel Li, Juno Therapeutics, Seattle, WA; and Arletta Lozanski and John C. Byrd, The Ohio State University, Columbus, OH
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507
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Olin JL, Griffiths CL, Smith MB. Venetoclax: A novel B-cell lymphoma-2 inhibitor for chronic lymphocytic leukemia and other hematologic malignancies. J Oncol Pharm Pract 2017; 24:517-524. [DOI: 10.1177/1078155217718383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Patients with chronic lymphocytic leukemia with the 17p deletion have a poor prognosis and treatment options are limited. Venetoclax, a novel B-cell lymphoma-2 inhibitor, has been approved for treatment-experienced chronic lymphocytic leukemia patients with the 17p deletion. A phase 1 dose-escalation study to 400 mg daily showed overall response rates across all doses of 79% with a complete response achieved in 20%. A phase 2 multicenter open-label study demonstrated overall response rate of 79.4% of patients (95% confidence interval 70.5–86.6) with median duration of follow-up of 12.1 months (IQR 10.1-14.2). Tumor lysis syndrome has been observed during initiation and titration. Assessing risk of tumor lysis syndrome prior to therapy initiation is essential to provide appropriate prophylactic medications. Neutropenia, potentially warranting dose reduction or discontinuation, has been observed. Venetoclax has demonstrated activity in other leukemias, multiple myeloma, and lymphomas. Venetoclax has shown response, and is well tolerated in patients with highly resistant chronic lymphocytic leukemia. It has the potential to be part of the treatment armamentarium for other malignancies.
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Affiliation(s)
- Jacqueline L Olin
- Levine College of Health Sciences, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Carrie L Griffiths
- Levine College of Health Sciences, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Morgan B Smith
- Hematology/Oncology, Novant Health Presbyterian Medical Center, Charlotte, NC, USA
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508
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Seiler T, Dreyling M. Bruton’s tyrosine kinase inhibitors in B-cell lymphoma: current experience and future perspectives. Expert Opin Investig Drugs 2017; 26:909-915. [DOI: 10.1080/13543784.2017.1349097] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- T. Seiler
- Department of Internal Medicine III, University Hospital Grosshadern, Ludwig Maximilians University (LMU), Munich, Germany
| | - M. Dreyling
- Department of Internal Medicine III, University Hospital Grosshadern, Ludwig Maximilians University (LMU), Munich, Germany
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509
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Affiliation(s)
- Shinichi Makita
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Kensei Tobinai
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
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510
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Clinicopathological features and outcomes of progression of CLL on the BCL2 inhibitor venetoclax. Blood 2017; 129:3362-3370. [DOI: 10.1182/blood-2017-01-763003] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/23/2017] [Indexed: 12/18/2022] Open
Abstract
Key Points
Complex karyotype and fludarabine refractoriness are key risk factors for progression of CLL on venetoclax. Bruton tyrosine kinase inhibitors are active in patients with CLL after prior therapy with venetoclax.
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511
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512
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Wang J, Yang D, Luo Q, Qiu M, Zhang L, Li B, Chen H, Yi H, Yan X, Li S, Sun J. APG-1252-12A induces mitochondria-dependent apoptosis through inhibiting the antiapoptotic proteins Bcl-2/Bcl-xl in HL-60 cells. Int J Oncol 2017; 51:563-572. [DOI: 10.3892/ijo.2017.4028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/22/2017] [Indexed: 11/06/2022] Open
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513
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Wendtner CM, Gregor M. Current perspectives on the role of chemotherapy in chronic lymphocytic leukemia. Leuk Lymphoma 2017; 59:300-310. [PMID: 28565930 DOI: 10.1080/10428194.2017.1330474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Chemotherapy has long been integral to the treatment of chronic lymphocytic leukemia (CLL). Fludarabine/cyclophosphamide, chlorambucil and bendamustine are commonly used as a backbone, depending on the patient's age and general health. The advent of the anti-CD20 monoclonal antibodies, such as rituximab and obinutuzumab, altered the face of treatment, and chemoimmunotherapy still forms the current standard first-line approach. However, the landscape is changing following the emergence of novel targeted agents, such as ibrutinib, idelalisib and venetoclax, which offer the chance for improved efficacy over standard therapy alone, with no substantial increase in toxicity. This review focuses on the role of chemotherapy in CLL, discussing the characteristics that define a state-of-the art chemotherapy, the current role of chemotherapy in the treatment of CLL, within the context of guidelines, and its future role in a setting in which chemotherapy-free regimens are being increasingly investigated.
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Affiliation(s)
- Clemens-Martin Wendtner
- a Klinikum Schwabing, Department of Internal Medicine I , Academic Teaching Hospital of University of Munich , Munich , Germany
| | - Michael Gregor
- b Division of Hematology , Luzerner Kantonsspital , Lucerne , Switzerland
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514
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Crombie J, Davids MS. Venetoclax for the treatment of patients with chronic lymphocytic leukemia. Future Oncol 2017; 13:1223-1232. [DOI: 10.2217/fon-2017-0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Venetoclax is a potent, selective inhibitor of BCL-2, a key regulator of the intrinsic pathway of apoptosis. In preclinical studies, venetoclax bound to BCL-2 with high affinity and rapidly induced apoptosis in chronic lymphocytic leukemia (CLL) cells. In early-phase clinical trials in CLL, venetoclax treatment led to tumor lysis syndrome in some patients with a large tumor burden, but this risk was subsequently mitigated by a revised study design that included lower initial dosing with intrapatient dose ramp up and close tumor lysis syndrome monitoring and prophylaxis. Other toxicities, such as neutropenia and gastrointestinal adverse events, were manageable. Venetoclax monotherapy resulted in durable and deep responses in patients with relapsed, refractory CLL, including for those with deletion 17p, leading to the approval of venetoclax by the US FDA for relapsed or refractory deletion 17p CLL, and recently to additional approvals in Europe and Canada. Trials also suggest that venetoclax induces deeper and more durable responses when used in combination with rituximab, and combination studies with other agents are ongoing. Phase III trials are also underway, and will provide data on the efficacy and safety of venetoclax in combination with monoclonal antibodies and targeted therapies in larger patient populations.
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Affiliation(s)
- Jennifer Crombie
- Write Affiliation text here. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S. Davids
- Write Affiliation text here. Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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515
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Zahr AA, Bose P, Keating MJ. Pharmacotherapy of relapsed/refractory chronic lymphocytic leukemia. Expert Opin Pharmacother 2017; 18:857-873. [PMID: 28446054 PMCID: PMC6488229 DOI: 10.1080/14656566.2017.1324420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The treatment of relapsed/refractory (RR) CLL has been revolutionized by the advent of the new oral inhibitors of B-cell receptor (BCR) signaling and the pro-survival protein, B-cell lymphoma 2 (BCL2). Additionally, new and more potent monoclonal antibodies against CD20 have replaced/may replace rituximab in many settings. Areas covered: Herein, we review the entire therapeutic landscape of RR CLL, with particular attention to the new small-molecule kinase inhibitors and BH3-mimetics. We discuss preclinical data with these agents in CLL, cover available efficacy and safety information, and examine potential resistance mechanisms and possible rational combinations to circumvent them. Expert opinion: The availability of potent and selective inhibitors of BCR signaling and of the anti-apoptotic functions of BCL2 has enormously enhanced our therapeutic armamentarium, with unprecedented efficacy now observed in patients who historically had poor outcomes with chemoimmunotherapy (CIT), e.g., those with deletion 17p/11q and/or IGHV-unmutated disease. The next challenge is to optimally sequence these agents and develop rational combinations that will hopefully lead to deeper and more durable remissions than ever seen before. Indeed, long term relapse free survival, already achievable with CIT in patients with genetically favorable-risk disease, now appears to be a realistic possibility for most patients with CLL.
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MESH Headings
- Adult
- Agammaglobulinaemia Tyrosine Kinase
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- CD28 Antigens/antagonists & inhibitors
- CD28 Antigens/immunology
- Clinical Trials as Topic
- Drug Interactions
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/enzymology
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Protein-Tyrosine Kinases/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Recurrence
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Rituximab/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Abdallah Abou Zahr
- Department of Leukemia, University of Texas MD Anderson
Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson
Cancer Center, Houston, TX, USA
| | - Michael J. Keating
- Department of Leukemia, University of Texas MD Anderson
Cancer Center, Houston, TX, USA
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516
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Edenhofer SA, Stilgenbauer S. Chronic Lymphocytic Leukemia With TP53 Aberrations: Breakthroughs and Challenges. J Oncol Pract 2017; 13:381-382. [DOI: 10.1200/jop.2017.024562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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517
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Freise KJ, Jones AK, Verdugo ME, Menon RM, Maciag PC, Salem AH. Moving Beyond Maximum Tolerated Dose for Targeted Oncology Drugs: Use of Clinical Utility Index to Optimize Venetoclax Dosage in Multiple Myeloma Patients. Clin Pharmacol Ther 2017; 102:970-976. [PMID: 28419431 DOI: 10.1002/cpt.712] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/07/2017] [Accepted: 04/09/2017] [Indexed: 12/15/2022]
Abstract
Exposure-response analyses of venetoclax in combination with bortezomib and dexamethasone in previously treated patients with multiple myeloma (MM) were performed on a phase Ib venetoclax dose-ranging study. Logistic regression models were utilized to determine relationships, identify subpopulations with different responses, and optimize the venetoclax dosage that balanced both efficacy and safety. Bortezomib refractory status and number of prior treatments were identified to impact the efficacy response to venetoclax treatment. Higher venetoclax exposures were estimated to increase the probability of achieving a very good partial response (VGPR) or better through venetoclax doses of 1,200 mg. However, the probability of neutropenia (grade ≥3) was estimated to increase at doses >800 mg. Using a clinical utility index, a venetoclax dosage of 800 mg daily was selected to optimally balance the VGPR or better rates and neutropenia rates in MM patients administered 1-3 prior lines of therapy and nonrefractory to bortezomib.
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Affiliation(s)
- K J Freise
- AbbVie Inc., North Chicago, Illinois, USA
| | - A K Jones
- AbbVie Inc., North Chicago, Illinois, USA.,Indivior Inc., Richmond, Virginia, USA
| | | | - R M Menon
- AbbVie Inc., North Chicago, Illinois, USA
| | - P C Maciag
- AbbVie Inc., North Chicago, Illinois, USA
| | - A H Salem
- AbbVie Inc., North Chicago, Illinois, USA
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518
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Rafei H, Kharfan-Dabaja MA. Treatment of Del17p and/or aberrant TP53 chronic lymphocytic leukemia in the era of novel therapies. Hematol Oncol Stem Cell Ther 2017; 11:1-12. [PMID: 28549767 DOI: 10.1016/j.hemonc.2017.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 04/11/2017] [Indexed: 01/21/2023] Open
Abstract
More effective therapies are emerging, with better toxicity profiles, and are being incorporated into modern treatment algorithms of chronic lymphocytic leukemia at various stages of the disease, including for patients harboring Del17p and/or aberrant TP53. Ibrutinib, an inhibitor of Bruton's tyrosine kinase, has demonstrated impressive response rates in the relapsed/refractory setting, including in the setting of Del17p and/or TP53 mutations. Venetoclax, an inhibitor of BCL-2 known to play an important role in regulating cell death, has been approved recently for treatment of patients with chronic lymphocytic leukemia with Del17p who have received at least one prior therapy. Unfortunately, a cure remains unattainable unless eligible patients are offered an allogeneic hematopoietic cell transplant. However, hematopoietic cell allografting is limited by the availability of suitable donors and significant morbidity and mortality. Recent clinical practice recommendations by the American Society for Blood and Marrow Transplantation have relegated the role of transplantation to later stages of the disease. In patients with evidence of Richter syndrome, frontline consolidation allogeneic hematopoietic cell transplantation remains the most desirable approach owing to the limited activity of ibrutinib or other novel therapies. Further therapeutic advances would require enrolling these patients in large clinical trials that evaluate novel therapies alone or in combination with traditional chemotherapies or even in the setting of posttransplant consolidation/maintenance.
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Affiliation(s)
- Hind Rafei
- Department of Internal Medicine, George Washington University School of Medicine, Washington, DC, USA
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Department of Oncologic Sciences, College of Medicine, University of South Florida Morsani, Tampa, FL, USA.
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519
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Karpel-Massler G, Ishida CT, Bianchetti E, Shu C, Perez-Lorenzo R, Horst B, Banu M, Roth KA, Bruce JN, Canoll P, Altieri DC, Siegelin MD. Inhibition of Mitochondrial Matrix Chaperones and Antiapoptotic Bcl-2 Family Proteins Empower Antitumor Therapeutic Responses. Cancer Res 2017; 77:3513-3526. [PMID: 28522750 DOI: 10.1158/0008-5472.can-16-3424] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/22/2017] [Accepted: 04/28/2017] [Indexed: 11/16/2022]
Abstract
Rational therapeutic approaches based on synthetic lethality may improve cancer management. On the basis of a high-throughput drug screen, we provide preclinical proof of concept that targeting the mitochondrial Hsp90 chaperone network (mtHsp90) and inhibition of Bcl-2, Bcl-xL, and Mcl-1 is sufficient to elicit synthetic lethality in tumors recalcitrant to therapy. Our analyses focused on BH3 mimetics that are broad acting (ABT263 and obatoclax) or selective (ABT199, WEHI-539, and A1210477), along with the established mitochondrial matrix chaperone inhibitor gamitrinib-TPP. Drug combinations were tested in various therapy-resistant tumors in vitro and in vivo in murine model systems of melanoma, triple-negative breast cancer, and patient-derived orthotopic xenografts (PDX) of human glioblastoma. We found that combining BH3 mimetics and gamitrinib-TPP blunted cellular proliferation in a synergistic manner by massive activation of intrinsic apoptosis. In like manner, suppressing either Bcl-2, Bcl-xL, or Mcl-1 recapitulated the effects of BH3 mimetics and enhanced the effects of gamitrinib-TPP. Mechanistic investigations revealed that gamitrinib-TPP activated a PERK-dependent integrated stress response, which activated the proapoptotic BH3 protein Noxa and its downstream targets Usp9X and Mcl-1. Notably, in the PDX glioblastoma and BRAFi-resistant melanoma models, this drug combination safely and significantly extended host survival. Our results show how combining mitochondrial chaperone and Bcl-2 family inhibitors can synergize to safely degrade the growth of tumors recalcitrant to other treatments. Cancer Res; 77(13); 3513-26. ©2017 AACR.
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Affiliation(s)
- Georg Karpel-Massler
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | - Chiaki Tsuge Ishida
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | - Elena Bianchetti
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | - Chang Shu
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | | | - Basil Horst
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
- Department of Dermatology, Columbia University Medical Center, New York, New York
| | - Matei Banu
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - Kevin A Roth
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | - Jeffrey N Bruce
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - Peter Canoll
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York
| | | | - Markus D Siegelin
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York.
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520
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Kubuschok B, Trepel M. Learning from the failures of drug discovery in B-cell non-Hodgkin lymphomas and perspectives for the future: chronic lymphocytic leukemia and diffuse large B-cell lymphoma as two ends of a spectrum in drug development. Expert Opin Drug Discov 2017; 12:733-745. [PMID: 28494631 DOI: 10.1080/17460441.2017.1329293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Despite substantial recent advances, there is still an unmet need for better therapies in B-cell non Hodgkin lymphomas (B-NHL), especially in relapsed or refractory disease. Many novel targeted drugs have been developed based on a better molecular understanding of B-NHL. Areas covered: This article focuses on chronic lymphocytic leukemia (CLL) as a representative for indolent lymphomas and paradigmatic for the tremendous progress in treating B-NHL on the one hand and diffuse large B-cell lymphoma (DLBCL) as a representative for aggressive lymphomas and paradigmatic for many unsolved problems in lymphoma treatment or the other hand. We highlight salient points in current therapies targeting genetic, epigenetic, immunological and microenvironmental alterations. Possible reasons for drug failure in clinical trials like tumor heterogeneity, clonal evolution and drug resistance mechanisms are discussed. Based thereon, some perspectives for further drug discovery are given. Expert opinion: In view of the pathogenetic complexity of lymphomas, therapies targeting exclusively a single alteration may fail because resistance mechanisms are present either initially or evolve during treatment. Therefore, future therapies in B-NHL may have to target the greatest possible number of genetic, immunological or epigenetic alterations still allowing tolerability and to monitor these alterations during therapy.
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Affiliation(s)
- Boris Kubuschok
- a Department of Internal Medicine II , Klinikum Augsburg , Augsburg , Germany.,b Department of Hematology and Oncology , University of Saarland Medical School , Homburg , Germany
| | - Martin Trepel
- a Department of Internal Medicine II , Klinikum Augsburg , Augsburg , Germany.,c Department of Oncology and Hematology , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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521
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Aw A, Brown JR. The potential combination of BCL-2 inhibitors and ibrutinib as frontline therapy in chronic lymphocytic leukemia. Leuk Lymphoma 2017; 58:2287-2297. [PMID: 28482721 DOI: 10.1080/10428194.2017.1312387] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The recent development of small molecule inhibitors targeted at the B-cell receptor (BCR) pathway and the anti-apoptotic protein BCL-2 has revolutionized the care of patients with chronic lymphocytic leukemia (CLL). While durable responses to the BCR inhibitor ibrutinib have been observed in both previously untreated and relapsed/refractory CLL patients, residual disease is common in patients treated with single-agent ibrutinib. Interest remains high in therapeutic combinations that may lead to better quality remissions. A potential partner to ibrutinib with a distinct mechanism of action that is likely to lead to deeper responses is the BCL-2 inhibitor venetoclax. Preclinical studies have suggested synergism between inhibitors of BCR and BCL-2 and have paved the way to the development of ongoing clinical trials aimed at evaluating the combination of ibrutinib with venetoclax in CLL patients.
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Affiliation(s)
- Andrew Aw
- a Department of Medicine, Division of Hematology , The Ottawa Hospital, University of Ottawa , Ottawa , Canada
| | - Jennifer R Brown
- b CLL Center, Department of Medical Oncology , Dana-Farber Cancer Institute , Boston , MA , USA.,c Department of Medicine , Harvard Medical School , Boston , MA , USA
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522
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Vogler M, Walter HS, Dyer MJS. Targeting anti-apoptotic BCL2 family proteins in haematological malignancies - from pathogenesis to treatment. Br J Haematol 2017; 178:364-379. [DOI: 10.1111/bjh.14684] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Meike Vogler
- Department of Molecular and Cell Biology; University of Leicester; Leicester UK
- Institute for Experimental Cancer Research in Paediatrics; Goethe-University; Frankfurt Germany
| | - Harriet S. Walter
- Ernest and Helen Scott Haematological Research Institute; University of Leicester; Leicester UK
| | - Martin J. S. Dyer
- Ernest and Helen Scott Haematological Research Institute; University of Leicester; Leicester UK
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523
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Molica S. Targeted therapy in the treatment of chronic lymphocytic leukemia: facts, shortcomings and hopes for the future. Expert Rev Hematol 2017; 10:425-432. [DOI: 10.1080/17474086.2017.1313108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Stefano Molica
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
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524
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Salem AH, Hu B, Freise KJ, Agarwal SK, Sidhu DS, Wong SL. Evaluation of the Pharmacokinetic Interaction between Venetoclax, a Selective BCL-2 Inhibitor, and Warfarin in Healthy Volunteers. Clin Drug Investig 2017; 37:303-309. [PMID: 27910036 DOI: 10.1007/s40261-016-0485-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Venetoclax is a selective, B-cell lymphoma-2 inhibitor that has demonstrated clinical efficacy in a variety of hematological malignancies. In vitro data indicated weak cytochrome P450 (CYP) 2C9 inhibition by venetoclax; however, it is not predicted to cause clinically relevant inhibition due to high plasma protein binding. A Phase 1 study was conducted in healthy volunteers to evaluate the effect of venetoclax on warfarin pharmacokinetics. METHODS Subjects received a single oral dose of 5 mg warfarin on day 1 of both periods 1 and 2, separated by a 14 days washout. On day 1 of period 2, subjects concomitantly received a single 400 mg oral dose of venetoclax. Blood samples for warfarin concentration determination were collected after each dose administration for up to 9 days. RESULTS Modest increases of 18 to 28% were observed in the maximum observed plasma concentration (C max) and area under the curve from time zero to infinity (AUC∞) of both R- and S-warfarin. CONCLUSIONS Due to the narrow therapeutic window of warfarin, it is recommended that the international normalized ratio (INR) be monitored closely in patients receiving venetoclax and warfarin. Since similar increases in exposure were observed for both enantiomers, even though CYP2C9 is only involved in the metabolism of the S-enantiomer, and the half-life of both enantiomers remained the same, the interaction does not appear to be mediated via CYP2C9.
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Affiliation(s)
- Ahmed Hamed Salem
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA. .,Department of Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt.
| | - Beibei Hu
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Kevin J Freise
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Suresh K Agarwal
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Dilraj S Sidhu
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Shekman L Wong
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
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525
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Advances in the treatment of relapsed/refractory chronic lymphocytic leukemia. Ann Hematol 2017; 96:1185-1196. [PMID: 28389687 PMCID: PMC5486803 DOI: 10.1007/s00277-017-2982-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/21/2017] [Indexed: 11/25/2022]
Abstract
Treatment of chronic lymphocytic leukemia (CLL) has advanced with the introduction of chemoimmunotherapy (CIT) agents that have improved the outcomes of frontline therapy. However, most treated patients will relapse and require subsequent therapy. This review focuses on recent advances in the treatment of relapsed or refractory CLL. Until recently, treatment options for relapsed CLL were of limited efficacy. Retreatment with fludarabine, cyclophosphamide, and rituximab (FCR) was recommended for patients with a durable response to first-line FCR, although acquired genetic aberrations, impaired marrow reserve, and comorbidities often made this suboptimal therapy for many patients. New options include two agents targeting B cell receptor (BCR) signaling pathways (ibrutinib and idelalisib) and a B cell lymphoma-2 (BCL-2) inhibitor (venetoclax). Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potentially curative option for younger patients with a suitable donor.
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526
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Carrington EM, Zhan Y, Brady JL, Zhang JG, Sutherland RM, Anstee NS, Schenk RL, Vikstrom IB, Delconte RB, Segal D, Huntington ND, Bouillet P, Tarlinton DM, Huang DC, Strasser A, Cory S, Herold MJ, Lew AM. Anti-apoptotic proteins BCL-2, MCL-1 and A1 summate collectively to maintain survival of immune cell populations both in vitro and in vivo. Cell Death Differ 2017; 24:878-888. [PMID: 28362427 DOI: 10.1038/cdd.2017.30] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 12/12/2022] Open
Abstract
Survival of various immune cell populations has been proposed to preferentially rely on a particular anti-apoptotic BCL-2 family member, for example, naive T cells require BCL-2, while regulatory T cells require MCL-1. Here we examined the survival requirements of multiple immune cell subsets in vitro and in vivo, using both genetic and pharmacological approaches. Our findings support a model in which survival is determined by quantitative participation of multiple anti-apoptotic proteins rather than by a single anti-apoptotic protein. This model provides both an insight into how the sum of relative levels of anti-apoptotic proteins BCL-2, MCL-1 and A1 influence survival of T cells, B cells and dendritic cells, and a framework for ascertaining how these different immune cells can be optimally targeted in treatment of immunopathology, transplantation rejection or hematological cancers.
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Affiliation(s)
- Emma M Carrington
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Yifan Zhan
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Jamie L Brady
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Jian-Guo Zhang
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Robyn M Sutherland
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Natasha S Anstee
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Robyn L Schenk
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Ingela B Vikstrom
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia
| | - Rebecca B Delconte
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - David Segal
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Nicholas D Huntington
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Philippe Bouillet
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - David M Tarlinton
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia.,Department of Immunology & Pathology, Monash University, Melbourne, VIC 3004, Australia
| | - David Cs Huang
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Andreas Strasser
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Suzanne Cory
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Marco J Herold
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia
| | - Andrew M Lew
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC 3010, Australia.,Department of Microbiology & Immunology, University of Melbourne, Parkville, VIC 3010, Australia
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527
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Waldron M, Winter A, Hill BT. Pharmacokinetic and Pharmacodynamic Considerations in the Treatment of Chronic Lymphocytic Leukemia: Ibrutinib, Idelalisib, and Venetoclax. Clin Pharmacokinet 2017; 56:1255-1266. [DOI: 10.1007/s40262-017-0529-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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528
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Kaur V, Swami A. Ibrutinib in CLL: a focus on adverse events, resistance, and novel approaches beyond ibrutinib. Ann Hematol 2017; 96:1175-1184. [DOI: 10.1007/s00277-017-2973-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/06/2017] [Indexed: 11/29/2022]
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529
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530
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D'Orsi B, Mateyka J, Prehn JHM. Control of mitochondrial physiology and cell death by the Bcl-2 family proteins Bax and Bok. Neurochem Int 2017; 109:162-170. [PMID: 28315370 DOI: 10.1016/j.neuint.2017.03.010] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 01/14/2023]
Abstract
Neuronal cell death is often triggered by events that involve intracellular increases in Ca2+. Under resting conditions, the intracellular Ca2+ concentration is tightly controlled by a number of extrusion and sequestering mechanisms involving the plasma membrane, mitochondria, and ER. These mechanisms act to prevent a disruption of neuronal ion homeostasis. As these processes require ATP, excessive Ca2+ overloading may cause energy depletion, mitochondrial dysfunction, and may eventually lead to Ca2+-dependent cell death. Excessive Ca2+ entry though glutamate receptors (excitotoxicity) has been implicated in several neurologic and chronic neurodegenerative diseases, including ischemic stroke, epilepsy, and Alzheimer's disease. Recent evidence has revealed that excitotoxic cell death is regulated by the B-cell lymphoma-2 (Bcl-2) family of proteins. Bcl-2 proteins, comprising of both pro-apoptotic and anti-apoptotic members, have been shown to not only mediate the intrinsic apoptosis pathway by controlling mitochondrial outer membrane (MOM) integrity, but to also control neuronal Ca2+ homeostasis and energetics. In this review, the role of Bcl-2 family proteins in the regulation of apoptosis, their expression in the central nervous system and how they control Ca2+-dependent neuronal injury are summarized. We review the current knowledge on Bcl-2 family proteins in the regulation of mitochondrial function and bioenergetics, including the fusion and fission machinery, and their role in Ca2+ homeostasis regulation at the mitochondria and ER. Specifically, we discuss how the 'pro-apoptotic' Bcl-2 family proteins, Bax and Bok, physiologically expressed in the nervous system, regulate such 'non-apoptotic/daytime' functions.
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Affiliation(s)
- Beatrice D'Orsi
- Department of Physiology & Medical Physics, Centre for the Study of Neurological Disorders, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Julia Mateyka
- Department of Physiology & Medical Physics, Centre for the Study of Neurological Disorders, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Jochen H M Prehn
- Department of Physiology & Medical Physics, Centre for the Study of Neurological Disorders, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
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531
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Abstract
B-cell lymphoma-2 (BCL-2) family dysfunction and impairment of apoptosis are common in most B-cell lymphoid malignancies. Venetoclax (Venclexta™, formerly ABT-199, GDC-0199) is a highly selective BCL-2 inhibitor, which mimics its BCL-2 homology 3-domain to induce apoptosis. It was approved for treatment of previously treated chronic lymphocytic leukemia (CLL) patients with 17p deletion early in 2016. It has also been in clinical trials for other B-cell lymphoid malignancies. Unlike the other recently approved targeted agents idelalisib and ibrutinib, so far there has been no relapse reported in some patients. Also, unlike the other targeted agents, it is effective against tumor cells that reside in the blood marrow. Despite its promising outcome in CLL, preclinical data have already uncovered mechanistic insights underlying venetoclax resistance, such as upregulation of MCL-1 or BCL-xL expression and protective signaling from the microenvironment. In this review, we describe the role of the BCL-2 family in the pathogenesis of B-cell lymphoid malignancies, the development of venetoclax, and its current clinical outcome in CLL and other B-cell malignancies. We also discuss the resistance mechanisms that develop following venetoclax therapy, potential strategies to overcome them, and how this knowledge can be translated into clinical applications.
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Affiliation(s)
- Huayuan Zhu
- Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People’s Republic of China
| | - Alexandru Almasan
- Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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532
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Affiliation(s)
- Anthony Letai
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts 02215
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533
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Savage P. Approvals in 2016: cost–benefit challenges of new anticancer agents. Nat Rev Clin Oncol 2017; 14:133-134. [DOI: 10.1038/nrclinonc.2017.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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534
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Egle A. Milestones in Chronic Lymphocytic Leukemia: An exciting decade of progress-10th anniversary of memo. MEMO 2017; 10:8-12. [PMID: 28367250 PMCID: PMC5357250 DOI: 10.1007/s12254-017-0318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/03/2017] [Indexed: 06/07/2023]
Abstract
The past 10 years have been an exciting ride for Chronic Lymphocytic Leukemia (CLL) aficionados. An overview of changes in management paradigms in CLL, ranging from insights into biology, via chemotherapy and chemoimmunotherapy to maintenance and novel drugs will be presented.
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Affiliation(s)
- Alexander Egle
- 3rd Medical Department, Paracelsus Private Medical University Hospital Salzburg, Muellnerhauptstrasse 48, 5020 Salzburg, Austria
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535
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Vitale C, Griggio V, Todaro M, Salvetti C, Boccadoro M, Coscia M. Magic pills: new oral drugs to treat chronic lymphocytic leukemia. Expert Opin Pharmacother 2017; 18:411-425. [DOI: 10.1080/14656566.2017.1293655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Candida Vitale
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Valentina Griggio
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Maria Todaro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Chiara Salvetti
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Mario Boccadoro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Marta Coscia
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
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536
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Barile E, Marconi GD, De SK, Baggio C, Gambini L, Salem AF, Kashyap MK, Castro JE, Kipps TJ, Pellecchia M. hBfl-1/hNOXA Interaction Studies Provide New Insights on the Role of Bfl-1 in Cancer Cell Resistance and for the Design of Novel Anticancer Agents. ACS Chem Biol 2017; 12:444-455. [PMID: 28026162 PMCID: PMC5320539 DOI: 10.1021/acschembio.6b00962] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Upregulation of antiapoptotic Bcl-2 proteins in certain tumors confers cancer cell resistance to chemotherapy or radiations. Members of the antiapoptotic Bcl-2 proteins, including Bcl-2, Mcl-1, Bcl-xL, Bcl-w, and Bfl-1, inhibit apoptosis by selectively binding to conserved α-helical regions, named BH3 domains, of pro-apoptotic proteins such as Bim, tBid, Bad, or NOXA. Five antiapoptotic proteins have been identified that interact with various selectivity with BH3 containing pro-apoptotic counterparts. Cancer cells present various and variable levels of these proteins, making the design of effective apoptosis based therapeutics challenging. Recently, BH3 profiling was introduced as a method to classify cancer cells based on their ability to resist apoptosis following exposure to selected BH3 peptides. However, these studies were based on binding affinities measured with model BH3 peptides and Bcl-2-proteins taken from mouse sequences. While the majority of these interactions are conserved between mice and humans, we found surprisingly that human NOXA binds to human Bfl-1 potently and covalently via conserved Cys residues, with over 2 orders of magnitude increased affinity over hMcl-1. Our data suggest that some assumptions of the original BH3 profiling need to be revisited and that perhaps further targeting efforts should be redirected toward Bfl-1, for which no suitable specific inhibitors or pharmacological tools have been reported. In this regard, we also describe the initial design and characterizations of novel covalent BH3-based agents that potently target Bfl-1. These molecules could provide a novel platform on which to design effective Bfl-1 targeting therapeutics.
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Affiliation(s)
- Elisa Barile
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Guya D. Marconi
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Surya K. De
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Carlo Baggio
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Luca Gambini
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Ahmed F. Salem
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
| | - Manoj K. Kashyap
- Moores Cancer Center, University of California, San Diego, La Jolla, California 92093, United States
- CLL Research
Consortium, and Department of Medicine, University of California, San Diego, La Jolla, California 92093, United States
| | - Januario E. Castro
- Moores Cancer Center, University of California, San Diego, La Jolla, California 92093, United States
- CLL Research
Consortium, and Department of Medicine, University of California, San Diego, La Jolla, California 92093, United States
| | - Thomas J. Kipps
- Moores Cancer Center, University of California, San Diego, La Jolla, California 92093, United States
- CLL Research
Consortium, and Department of Medicine, University of California, San Diego, La Jolla, California 92093, United States
| | - Maurizio Pellecchia
- Division of Biomedical
Sciences, School of Medicine, University
of California, Riverside, 900 University Avenue, Riverside, California 92521, United States
- Phone: (951)-827-7829. E-mail:
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537
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Ashkenazi A, Fairbrother WJ, Leverson JD, Souers AJ. From basic apoptosis discoveries to advanced selective BCL-2 family inhibitors. Nat Rev Drug Discov 2017; 16:273-284. [DOI: 10.1038/nrd.2016.253] [Citation(s) in RCA: 508] [Impact Index Per Article: 72.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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538
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Lazarian G, Guièze R, Wu CJ. Clinical Implications of Novel Genomic Discoveries in Chronic Lymphocytic Leukemia. J Clin Oncol 2017; 35:984-993. [PMID: 28297623 DOI: 10.1200/jco.2016.71.0822] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a common B-cell malignancy with a remarkably heterogeneous course, ranging from indolent disease with no need for immediate therapy to rapidly progressive disease associated with therapeutic resistance. The recent US Food and Drug Administration approvals of novel targeted therapies such as inhibitors of B-cell receptor signaling and B-cell lymphoma 2 have opened up new opportunities in the clinical management of patients with CLL and heralded a new era in the clinical treatment of this disease. In parallel, the implementation of novel sequencing technologies has provided new insights into CLL complexity, identifying a growing list of putative drivers that underlie inter- and intratumor heterogeneities in CLL affecting disease progression and resistance. The identification of these novel genomic features that can indicate future drug resistance or guide therapeutic management is now becoming a major goal in CLL so that patients can best benefit from the increasingly diverse available therapies, as discussed herein.
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Affiliation(s)
- Gregory Lazarian
- All authors: Dana-Farber Cancer Institute; Romain Guièze and Catherine J. Wu, Harvard Medical School; Catherine J. Wu, Brigham and Women's Hospital, Boston; Romain Guièze and Catherine J. Wu, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA; Gregory Lazarian, U978 Institut National de la Santé et de la Recherche Médicale and Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny; and Romain Guièze, Centre Hospitalier Universitaire de Clermont-Ferrand and Université d'Auvergne, Clermont-Ferrand, France
| | - Romain Guièze
- All authors: Dana-Farber Cancer Institute; Romain Guièze and Catherine J. Wu, Harvard Medical School; Catherine J. Wu, Brigham and Women's Hospital, Boston; Romain Guièze and Catherine J. Wu, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA; Gregory Lazarian, U978 Institut National de la Santé et de la Recherche Médicale and Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny; and Romain Guièze, Centre Hospitalier Universitaire de Clermont-Ferrand and Université d'Auvergne, Clermont-Ferrand, France
| | - Catherine J Wu
- All authors: Dana-Farber Cancer Institute; Romain Guièze and Catherine J. Wu, Harvard Medical School; Catherine J. Wu, Brigham and Women's Hospital, Boston; Romain Guièze and Catherine J. Wu, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA; Gregory Lazarian, U978 Institut National de la Santé et de la Recherche Médicale and Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, Bobigny; and Romain Guièze, Centre Hospitalier Universitaire de Clermont-Ferrand and Université d'Auvergne, Clermont-Ferrand, France
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539
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Huber H, Edenhofer S, Estenfelder S, Stilgenbauer S. Profile of venetoclax and its potential in the context of treatment of relapsed or refractory chronic lymphocytic leukemia. Onco Targets Ther 2017; 10:645-656. [PMID: 28223822 PMCID: PMC5308588 DOI: 10.2147/ott.s102646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Over the last few years, dramatic changes have occurred in the treatment of chronic lymphocytic leukemia (CLL). The current standard for young and fit patients with CLL remains chemoimmunotherapy, namely the fludarabine, cyclophosphamide, and rituximab (FCR) regimen. However, novel oral therapies are presently being introduced and represent a considerable breakthrough concerning effectiveness and safety profile. In particular, the very high-risk group of CLL patients, defined by the genetic aberration del(17p) and/or TP53 mutation, benefit from the new agents. These genetic abnormalities are the most relevant negative prognostic markers in the context of chemoimmunotherapy. New targeted therapies allow different approaches to improve outcomes.
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Affiliation(s)
- Henriette Huber
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Simone Edenhofer
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Sven Estenfelder
- Department of Internal Medicine III, Ulm University, Ulm, Germany
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540
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Lampson BL, Davids MS. The Development and Current Use of BCL-2 Inhibitors for the Treatment of Chronic Lymphocytic Leukemia. Curr Hematol Malig Rep 2017; 12:11-19. [PMID: 28116634 PMCID: PMC5862560 DOI: 10.1007/s11899-017-0359-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The BCL-2 family of proteins integrates pro- and anti-apoptotic signals within the cell and is responsible for initiation of caspase-dependent apoptosis. Chronic lymphocytic leukemia (CLL) cells are particularly dependent on the anti-apoptotic protein BCL-2 for their survival, making this an attractive therapeutic target in CLL. Several early efforts to create inhibitors of the anti-apoptotic family members faced significant challenges, but eventually, the BCL-2 specific inhibitor venetoclax moved forward in CLL. Overall and complete response rates to venetoclax monotherapy in relapsed, refractory CLL are approximately 80 and 20%, respectively, even in patients with high-risk 17p deletion. Toxicities have been manageable and include neutropenia, diarrhea, and nausea. The risk of tumor lysis syndrome (TLS), seen in early experience with the drug, has been mitigated by the use of appropriate TLS risk assessment, prophylaxis, and management. Future studies of venetoclax will focus on combination approaches, predictive biomarker discovery, and mechanisms of resistance.
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Affiliation(s)
- Benjamin L Lampson
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA, 02215, USA.
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541
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Another treatment option for relapsed or refractory chronic lymphocytic leukaemia. Lancet Oncol 2017; 18:270-271. [PMID: 28139406 DOI: 10.1016/s1470-2045(16)30667-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 11/22/2022]
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542
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Agarwal SK, DiNardo CD, Potluri J, Dunbar M, Kantarjian HM, Humerickhouse RA, Wong SL, Menon RM, Konopleva MY, Salem AH. Management of Venetoclax-Posaconazole Interaction in Acute Myeloid Leukemia Patients: Evaluation of Dose Adjustments. Clin Ther 2017; 39:359-367. [DOI: 10.1016/j.clinthera.2017.01.003] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/08/2016] [Accepted: 01/03/2017] [Indexed: 11/29/2022]
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543
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Deng J, Isik E, Fernandes SM, Brown JR, Letai A, Davids MS. Bruton's tyrosine kinase inhibition increases BCL-2 dependence and enhances sensitivity to venetoclax in chronic lymphocytic leukemia. Leukemia 2017; 31:2075-2084. [PMID: 28111464 PMCID: PMC5555835 DOI: 10.1038/leu.2017.32] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/05/2017] [Accepted: 01/13/2017] [Indexed: 02/07/2023]
Abstract
Although the BTK inhibitor ibrutinib has transformed the management of patients with CLL, it does not induce substantial apoptosis in vitro, and as such the mechanisms underlying its ability to kill CLL cells are not well understood. Acalabrutinib, a more specific BTK inhibitor now in development, also appears to be highly effective in CLL, but the connection of its mechanism with CLL cell death is also unclear. Using dynamic BH3 profiling, we analyzed alterations in the function of the mitochondrial apoptotic pathway induced by ibrutinib and acalabrutinib. We studied CLL patient samples treated ex vivo with both drugs, as well as primary samples from CLL patients on clinical trials of both drugs. We found that BTK inhibition enhances mitochondrial BCL-2 dependence without significantly altering overall mitochondrial priming. Enhancement of BCL-2 dependence was accompanied by an increase in the pro-apoptotic protein BIM. In contrast, treatment with the selective BCL-2 inhibitor venetoclax enhanced overall mitochondrial priming without increasing BCL-2 dependence. Pre-treatment of CLL cells with either BTK inhibitor, whether ex vivo or in vivo in patients, enhanced killing by venetoclax. Our data suggest that BTK inhibition enhances mitochondrial BCL2 dependence, supporting the ongoing development of clinical trials combining BTK and BCL-2 inhibition.
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Affiliation(s)
- J Deng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - E Isik
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - S M Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - J R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - A Letai
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - M S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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544
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Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG, O'Brien S, Gribben J, Rai K. Chronic lymphocytic leukaemia. Nat Rev Dis Primers 2017; 3:16096. [PMID: 28102226 PMCID: PMC5336551 DOI: 10.1038/nrdp.2016.96] [Citation(s) in RCA: 287] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is a malignancy of CD5+ B cells that is characterized by the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues. Signalling via surface immunoglobulin, which constitutes the major part of the B cell receptor, and several genetic alterations play a part in CLL pathogenesis, in addition to interactions between CLL cells and other cell types, such as stromal cells, T cells and nurse-like cells in the lymph nodes. The clinical progression of CLL is heterogeneous and ranges from patients who require treatment soon after diagnosis to others who do not require therapy for many years, if at all. Several factors, including the immunoglobulin heavy-chain variable region gene (IGHV) mutational status, genomic changes, patient age and the presence of comorbidities, should be considered when defining the optimal management strategies, which include chemotherapy, chemoimmunotherapy and/or drugs targeting B cell receptor signalling or inhibitors of apoptosis, such as BCL-2. Research on the biology of CLL has profoundly enhanced our ability to identify patients who are at higher risk for disease progression and our capacity to treat patients with drugs that selectively target distinctive phenotypic or physiological features of CLL. How these and other advances have shaped our current understanding and treatment of patients with CLL is the subject of this Primer.
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Affiliation(s)
- Thomas J Kipps
- Division of Hematology-Oncology, Department of Medicine, Moores Cancer Centre, University of California, San Diego, 3855 Health Sciences Drive M/C 0820, La Jolla, California 92093, USA
| | - Freda K Stevenson
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Catherine J Wu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlo M Croce
- Department of Molecular Virology, Immunology and Medical Genetics, Ohio State University, Columbus, Ohio, USA
| | - Graham Packham
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - William G Wierda
- Department of Hematology, MD Anderson Cancer Centre, Houston, Texas, USA
| | - Susan O'Brien
- Division of Hematology, Department of Medicine, University of California, Irvine, California, USA
| | - John Gribben
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Kanti Rai
- CLL Research and Treatment Program, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York, USA
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545
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Roberts AW, Stilgenbauer S, Seymour JF, Huang DCS. Venetoclax in Patients with Previously Treated Chronic Lymphocytic Leukemia. Clin Cancer Res 2017; 23:4527-4533. [PMID: 28100580 DOI: 10.1158/1078-0432.ccr-16-0955] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/05/2016] [Accepted: 12/13/2016] [Indexed: 11/16/2022]
Abstract
Venetoclax is the first BCL2 inhibitor to enter routine clinical practice. It is an orally bioavailable small molecule that binds BCL2 very specifically. Acting as a pharmacologic mimic of the proteins that initiate apoptosis (a so-called BH3 mimetic), venetoclax rapidly induces apoptosis in chronic lymphocytic leukemia (CLL) cells, which express high levels of BCL2 and rely on it to maintain their survival. As a single agent, daily venetoclax treatment induced durable responses in 79% of patients with relapsed or refractory CLL or small lymphocytic lymphoma in a phase I study, including complete remissions in 20% of patients. Its use was approved by the FDA in April 2016 for patients with previously treated del(17p) CLL on the basis of a single-arm phase II trial demonstrating a 79% response rate and an estimated 1-year progression-free survival of 72% with 400 mg/day continuous therapy. This review focuses on venetoclax, its mechanism of action, pharmacology, and clinical trial data and seeks to place it in the context of rapid advances in therapy for patients with relapsed CLL, especially those with del(17p) CLL. Clin Cancer Res; 23(16); 4527-33. ©2017 AACR.
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Affiliation(s)
- Andrew W Roberts
- Integrated Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia. .,Cancer and Haematology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | | | - John F Seymour
- Integrated Department of Clinical Hematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Parkville, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Victorian Comprehensive Cancer Centre, Parkville, Victoria, Australia
| | - David C S Huang
- Cancer and Haematology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
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546
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Seymour JF, Ma S, Brander DM, Choi MY, Barrientos J, Davids MS, Anderson MA, Beaven AW, Rosen ST, Tam CS, Prine B, Agarwal SK, Munasinghe W, Zhu M, Lash LL, Desai M, Cerri E, Verdugo M, Kim SY, Humerickhouse RA, Gordon GB, Kipps TJ, Roberts AW. Venetoclax plus rituximab in relapsed or refractory chronic lymphocytic leukaemia: a phase 1b study. Lancet Oncol 2017; 18:230-240. [PMID: 28089635 DOI: 10.1016/s1470-2045(17)30012-8] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Selective BCL2 inhibition with venetoclax has substantial activity in patients with relapsed or refractory chronic lymphocytic leukaemia. Combination therapy with rituximab enhanced activity in preclinical models. The aim of this study was to assess the safety, pharmacokinetics, and activity of venetoclax in combination with rituximab. METHODS Adult patients with relapsed or refractory chronic lymphocytic leukaemia (according to the 2008 Modified International Workshop on CLL guidelines) or small lymphocytic lymphoma were eligible for this phase 1b, dose-escalation trial. The primary outcomes were to assess the safety profile, to determine the maximum tolerated dose, and to establish the recommended phase 2 dose of venetoclax when given in combination with rituximab. Secondary outcomes were to assess the pharmacokinetic profile and analyse efficacy, including overall response, duration of response, and time to tumour progression. Minimal residual disease was a protocol-specified exploratory objective. Central review of the endpoints was not done. Venetoclax was dosed daily using a stepwise escalation to target doses (200-600 mg) and then monthly rituximab commenced (375 mg/m2 in month 1 and 500 mg/m2 in months 2-6). Adverse events were graded according to the National Cancer Institute Common Terminology Criteria for adverse events version 4.0. Protocol-guided drug cessation was allowed for patients who achieved complete response (including complete response with incomplete marrow recovery) or negative bone marrow minimal residual disease. Analyses were done per protocol for all patients who commenced drug and included all patients who received at least one dose of venetoclax. Data were pooled across dose cohorts. Patients are still receiving therapy and follow-up is ongoing. The trial is registered at ClinicalTrials.gov, number NCT01682616. FINDINGS Between Aug 6, 2012, and May 28, 2014, we enrolled 49 patients. Common grade 1-2 toxicities included upper respiratory tract infections (in 28 [57%] of 49 patients), diarrhoea (27 [55%]), and nausea (25 [51%]). Grade 3-4 adverse events occurred in 37 (76%) of 49 patients; most common were neutropenia (26 [53%]), thrombocytopenia (eight [16%]), anaemia (seven [14%]), febrile neutropenia (six [12%]), and leucopenia (six [12%]). The most common serious adverse events were pyrexia (six [12%]), febrile neutropenia (five [10%]), lower respiratory tract infection, and pneumonia (each three [6%]). Clinical tumour lysis syndrome occurred in two patients (resulting in one death) who initiated venetoclax at 50 mg. After enhancing tumour lysis syndrome prophylaxis measures and commencing venetoclax at 20 mg, clinical tumour lysis syndrome did not occur. The maximum tolerated dose was not identified; the recommended phase 2 dose of venetoclax in combination with rituximab was 400 mg. Overall, 42 (86%) of 49 patients achieved a response, including a complete response in 25 (51%) of 49 patients. 2 year estimates for progression-free survival and ongoing response were 82% (95% CI 66-91) and 89% (95% CI 72-96), respectively. Negative marrow minimal residual disease was attained in 20 (80%) of 25 complete responders and 28 (57%) of 49 patients overall. 13 responders ceased all therapy; among these all 11 minimal residual disease-negative responders remain progression-free off therapy. Two with minimal residual disease-positive complete response progressed after 24 months off therapy and re-attained response after re-initiation of venetoclax. INTERPRETATION A substantial proportion of patients achieved an overall response with the combination of venetoclax and rituximab including 25 (51%) of 49 patients who achieved a complete response and 28 (57%) of 49 patients who achieved negative marrow minimal residual disease with acceptable safety. The depth and durability of responses observed with the combination offers an attractive potential treatment option for patients with relapsed or refractory chronic lymphocytic leukaemia and could allow some patients to maintain response after discontinuing therapy, a strategy that warrants further investigation in randomised studies. FUNDING AbbVie Inc and Genentech Inc.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Cohort Studies
- Drug Resistance, Neoplasm/drug effects
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Maximum Tolerated Dose
- Middle Aged
- Neoplasm Grading
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Remission Induction
- Rituximab/administration & dosage
- Salvage Therapy
- Sulfonamides/administration & dosage
- Survival Rate
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Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia.
| | - Shuo Ma
- Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Mary Ann Anderson
- Department of Clinical Haematology and BMT, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia; Division of Cancer and Haematology, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, VIC, Australia
| | | | | | - Constantine S Tam
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia
| | | | | | | | - Ming Zhu
- AbbVie, Inc, North Chicago, IL, USA
| | | | | | | | | | | | | | | | | | - Andrew W Roberts
- Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia; Department of Clinical Haematology and BMT, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia; Division of Cancer and Haematology, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, VIC, Australia
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547
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Targeting BET proteins improves the therapeutic efficacy of BCL-2 inhibition in T-cell acute lymphoblastic leukemia. Leukemia 2017; 31:2037-2047. [PMID: 28074072 DOI: 10.1038/leu.2017.10] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 12/02/2016] [Accepted: 12/12/2016] [Indexed: 01/02/2023]
Abstract
Inhibition of anti-apoptotic BCL-2 (B-cell lymphoma 2) has recently emerged as a promising new therapeutic strategy for the treatment of a variety of human cancers, including leukemia. Here, we used T-cell acute lymphoblastic leukemia (T-ALL) as a model system to identify novel synergistic drug combinations with the BH3 mimetic venetoclax (ABT-199). In vitro drug screening in primary leukemia specimens that were derived from patients with high risk of relapse or relapse and cell lines revealed synergistic activity between venetoclax and the BET (bromodomain and extraterminal) bromodomain inhibitor JQ1. Notably, this drug synergism was confirmed in vivo using T-ALL cell line and patient-derived xenograft models. Moreover, the therapeutic benefit of this drug combination might, at least in part, be mediated by an acute induction of the pro-apoptotic factor BCL2L11 and concomitant reduction of BCL-2 upon BET bromodomain inhibition, ultimately resulting in an enhanced binding of BIM (encoded by BCL2L11) to BCL-2. Altogether, our work provides a rationale to develop a new type of targeted combination therapy for selected subgroups of high-risk leukemia patients.
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548
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King AC, Peterson TJ, Horvat TZ, Rodriguez M, Tang LA. Venetoclax: A First-in-Class Oral BCL-2 Inhibitor for the Management of Lymphoid Malignancies. Ann Pharmacother 2017; 51:410-416. [DOI: 10.1177/1060028016685803] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the pharmacology, efficacy, and safety of venetoclax for treatment of lymphoid malignancies. Data Sources: A literature search was performed of PubMed and MEDLINE databases (2005 to September 2016), abstracts from the American Society of Hematology and the American Society of Clinical Oncology, and ongoing studies from clinicaltrials.gov. Searches were performed utilizing the following key terms: venetoclax, ABT-199, GDC-199, obatoclax, GX15-070, BCL-2 inhibitor, navitoclax, ABT-263, and Venclexta. Study Selection/Data Extraction: Studies of pharmacology, pharmacokinetics, pharmacodynamics, clinical efficacy, and safety of venetoclax in lymphoid malignancies were identified. Data Synthesis: Recently, treatment of B-cell lymphoproliferative disorders has shifted from conventional cytotoxic chemotherapy to novel small-molecule inhibitors. The advent of recently Food and Drug Administration–approved oral agents ibrutinib and idelalisib has shifted the paradigm of chronic lymphocytic leukemia (CLL) treatment; however, complete remission is uncommon, and the outcome for patients progressing on these treatments remains poor. Attention has been focused on a novel target, the B-cell lymphoma-2 protein (BCL-2), which serves an essential role in regulation of apoptosis. Venetoclax has demonstrated efficacy in multiple subtypes of lymphoid malignancies, including patients with relapsed/refractory CLL harboring deletion 17p, with an overall response rate of nearly 80%. Venetoclax is generally well tolerated, with the significant adverse effect being tumor lysis syndrome, for which there are formal management recommendations. Conclusion: Venetoclax has demonstrated promising results in relapsed/refractory lymphoid malignancies, with an acceptable adverse effect profile. As the role of BCL-2 inhibition in various malignancies becomes further elucidated, venetoclax may offer benefit to a myriad other patient populations.
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Affiliation(s)
- Amber C. King
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Troy Z. Horvat
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Laura A. Tang
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Freise KJ, Shebley M, Salem AH. Quantitative Prediction of the Effect of CYP3A Inhibitors and Inducers on Venetoclax Pharmacokinetics Using a Physiologically Based Pharmacokinetic Model. J Clin Pharmacol 2017; 57:796-804. [DOI: 10.1002/jcph.858] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/21/2016] [Indexed: 11/07/2022]
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550
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Cell death: From initial concepts to pathways to clinical applications – Personal reflections of a clinical researcher. Biochem Biophys Res Commun 2017; 482:445-449. [DOI: 10.1016/j.bbrc.2016.10.124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/24/2016] [Accepted: 10/27/2016] [Indexed: 01/30/2023]
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