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Bairey O, Siegal T. The possible role of maintenance treatment for primary central nervous system lymphoma. Blood Rev 2018; 32:378-386. [PMID: 29551465 DOI: 10.1016/j.blre.2018.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 02/27/2018] [Accepted: 03/09/2018] [Indexed: 12/22/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) is a rare and aggressive brain tumor. The prognosis is poor, with high rates of relapse and disease progression after treatment. In addition, PCNSL affects a largely older population, so that a significant proportion of patients are ineligible for intensive therapies and high-dose chemotherapy. The elderly patients are also susceptible to the accelerated and detrimental cognitive side effects of whole-brain irradiation which is an alternative consolidation to high-dose chemotherapy. Maintenance therapy has been shown to be a promising strategy to prolong remission time in other hematopoietic malignancies. Herein, we discuss the place of maintenance treatment in PCNSL in view of perspective obtained from hematological malignancies and non-Hodgkin's lymphoma.
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Affiliation(s)
- Osnat Bairey
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tali Siegal
- Neuro-Oncology Center, Davidoff Cancer Center, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.
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Viala M, Vinches M, Alexandre M, Mollevi C, Durigova A, Hayaoui N, Homicsko K, Cuenant A, Gongora C, Gianni L, Tosi D. Strategies for clinical development of monoclonal antibodies beyond first-in-human trials: tested doses and rationale for dose selection. Br J Cancer 2018; 118:679-697. [PMID: 29438365 PMCID: PMC5846071 DOI: 10.1038/bjc.2017.473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Our previous survey on first-in-human trials (FIHT) of monoclonal antibodies (mAbs) showed that, due to their limited toxicity, the recommended phase II dose (RP2D) was only tentatively defined. METHODS We identified, by MEDLINE search, articles on single-agent trials of mAbs with an FIHT included in our previous survey. For each mAb, we examined tested dose(s) and dose selection rationale in non-FIHTs (NFIHTs). We also assessed the correlation between doses tested in the registration trials (RTs) of all FDA-approved mAbs and the corresponding FIHT results. RESULTS In the 37 dose-escalation NFIHTs, the RP2D indication was still poorly defined. In phase II-III NFIHTs (n=103 on 37 mAbs), the FIHT RP2D was the only dose tested for five mAbs. For 16 mAbs, only doses different from the FIHT RP2D or the maximum administered dose (MAD) were tested and the dose selection rationale infrequently indicated. In the 60 RTs on 27 FDA-approved mAbs with available FIHT, the FIHT RP2D was tested only for two mAbs, and RT doses were much lower than the FIHT MAD. CONCLUSIONS The rationale beyond dose selection in phase II and III trials of mAbs is often unclear in published articles and not based on FIHT data.
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Affiliation(s)
- Marie Viala
- Institut du Cancer de Montpellier, Montpellier, France
| | - Marie Vinches
- Institut du Cancer de Montpellier, Montpellier, France
| | | | | | | | - Nadia Hayaoui
- Institut du Cancer de Montpellier, Montpellier, France
| | | | - Alice Cuenant
- Institut du Cancer de Montpellier, Montpellier, France
| | - Céline Gongora
- Institut de Recherche en Cancérologie de Montpellier, Inserm U1194, Montpellier, France
| | - Luca Gianni
- San Raffaele – Scientific Institute, Milan, Italy
| | - Diego Tosi
- Institut du Cancer de Montpellier, Montpellier, France
- Institut de Recherche en Cancérologie de Montpellier, Inserm U1194, Montpellier, France
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Jakšić B, Pejša V, Ostojić-Kolonić S, Kardum-Skelin I, Bašić-Kinda S, Coha B, Gverić-Krečak V, Vrhovac R, Jakšić O, Aurer I, Sinčić-Petričević J, Načinović-Duletić A, Nemet D. Guidelines for Diagnosis and Treatment of Chronic Lymphocytic Leukemia. Krohem B-Cll 2017. Acta Clin Croat 2018; 57:190-215. [PMID: 30256032 PMCID: PMC6400341 DOI: 10.20471/acc.2018.57.01.27] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/26/2017] [Indexed: 12/22/2022] Open
Abstract
Recent developments in the diagnosis and treatment of chronic lymphocytic leukemia (B-CLL) have led to change of approach in clinical practice. New treatments have been approved based on the results of randomized multicenter trials for first line and for salvage therapy, and the results of numerous ongoing clinical trials are permanently providing new answers and further refining of therapeutic strategies. This is paralleled by substantial increase in understanding the disease genetics due to major advances in the next generation sequencing (NGS) technology. We define current position of the Croatian Cooperative Group for Hematologic Disease on diagnosis and treatment of CLL in the transition from chemo-immunotherapy paradigm into a new one that is based on new diagnostic stratification and unprecedented therapeutic results of B-cell receptor inhibitors (BRI) and Bcl-2 antagonists. This is a rapidly evolving field as a great number of ongoing clinical trials con-stantly accumulate and provide new knowledge. We believe that novel therapy research including genomic diagnosis is likely to offer new options that will eventually lead to time limited therapies without chemotherapy and more effective clinical care for B-CLL based on individualized precision medicine.
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Affiliation(s)
- Branimir Jakšić
- Merkur University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vlatko Pejša
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Ika Kardum-Skelin
- Merkur University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Sandra Bašić-Kinda
- Dubrava University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Božena Coha
- Zagreb University Hospital Center, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Radovan Vrhovac
- Dubrava University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ozren Jakšić
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Igor Aurer
- Dubrava University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Antica Načinović-Duletić
- Osijek University Hospital Center, Faculty of Medicine, Josip Juraj University of Osijek, Osijek, Croatia
| | - Damir Nemet
- Dubrava University Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
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Cramer P, von Tresckow J, Bahlo J, Engelke A, Langerbeins P, Fink AM, Fischer K, Wendtner CM, Kreuzer KA, Stilgenbauer S, Böttcher S, Eichhorst B, Hallek M. CLL2-BXX Phase II trials: sequential, targeted treatment for eradication of minimal residual disease in chronic lymphocytic leukemia. Future Oncol 2018; 14:499-513. [PMID: 29465308 DOI: 10.2217/fon-2017-0442] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Four Phase II trials (clinical trials numbers: NCT02345863, NCT02401503, NCT02445131 and NCT02689141) evaluate a different combination of targeted agents in an all-comer population of approximately 60 patients with chronic lymphocytic leukemia irrespective of prior treatment, physical fitness and genetic risk factors. Patients with a higher tumor load start with a debulking treatment with bendamustine. The subsequent induction and maintenance treatment with an anti-CD20 antibody (obinutuzumab or ofatumumab) and a targeted oral agent (ibrutinib, idelalisib or venetoclax) are continued until achievement of a complete response and minimal residual disease negativity. CONCLUSION This strategy represents a new era of chronic lymphocytic leukemia therapy where chemotherapy is increasingly replaced by targeted agents and treatment duration is tailored to the patient's individual tumor load and response.
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Affiliation(s)
- Paula Cramer
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Julia von Tresckow
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Jasmin Bahlo
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Anja Engelke
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Petra Langerbeins
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Clemens-Martin Wendtner
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany.,Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases & Tropical Medicine, Klinikum Schwabing, Munich, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | | | - Sebastian Böttcher
- Department III of Internal Medicine, University Hospital Rostock, Rostock, Germany.,Department II of Internal Medicine, Campus Kiel, University of Schleswig-Holstein, Kiel, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine & Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital Cologne, Cologne, Germany
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ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Agents targeting lymphoid cells surface antigens [I]: CD19, CD20 and CD52). Clin Microbiol Infect 2018; 24 Suppl 2:S71-S82. [PMID: 29447988 DOI: 10.1016/j.cmi.2018.02.003] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/28/2018] [Accepted: 02/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting CD19, CD20 and CD52 and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Although CD19-targeted agents (blinatumomab or inebilizumab) are not associated with an increased risk of infection, they may cause IgG hypogammaglobulinaemia and neutropenia. The requirement for prolonged intravenous infusion of blinatumomab may increase the risk of catheter-associated bloodstream infections. Infection remains the most common non-haematological adverse effect of anti-CD20 monoclonal antibodies, including severe respiratory tract infection, hepatitis B virus (HBV) reactivation and varicella-zoster virus infection. Screening for chronic or resolved HBV infection is recommended for patients receiving anti-CD20 monoclonal antibodies. Antiviral prophylaxis should be offered for 12-18 months to hepatitis B surface antigen (HBsAg)-positive and HBsAg-negative/anti-hepatitis B core antibody (HBc)-positive patients. Anti-Pneumocystis prophylaxis should be considered in patients receiving concomitant chemotherapy, particularly steroids. Alemtuzumab (anti-CD52) increases the risk of infections, in particular among leukaemia and solid organ transplant patients. These populations benefit from anti-Pneumocystis prophylaxis, prevention strategies for cytomegalovirus infection, and screening for HBV, hepatitis C virus and tuberculosis. Antiviral prophylaxis for at least 6-12 months should be provided for HBsAg-positive patients. IMPLICATIONS As there are limited clinical data for many of the reviewed agents, special attention must be given to promptly detect and report emerging infectious complications.
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Dartigeas C, Van Den Neste E, Léger J, Maisonneuve H, Berthou C, Dilhuydy MS, De Guibert S, Leprêtre S, Béné MC, Nguyen-Khac F, Letestu R, Cymbalista F, Rodon P, Aurran-Schleinitz T, Vilque JP, Tournilhac O, Mahé B, Laribi K, Michallet AS, Delmer A, Feugier P, Lévy V, Delépine R, Colombat P, Leblond V. Rituximab maintenance versus observation following abbreviated induction with chemoimmunotherapy in elderly patients with previously untreated chronic lymphocytic leukaemia (CLL 2007 SA): an open-label, randomised phase 3 study. LANCET HAEMATOLOGY 2017; 5:e82-e94. [PMID: 29275118 DOI: 10.1016/s2352-3026(17)30235-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Most patients with chronic lymphocytic leukaemia relapse after initial therapy combining chemotherapy with rituximab. We assessed the efficacy and safety of rituximab maintenance treatment versus observation for elderly patients in remission after front-line abbreviated induction by fludarabine, cyclophosphamide, and rituximab (FCR). METHODS This randomised, open-label, multicentre phase 3 trial at 89 centres in France enrolled treatment-naive and fit patients aged 65 years or older with chronic lymphocytic leukaemia without del(17p). Eligible patients had an Eastern Cooperative Oncology Group performance status of 0-1 and adequate renal and hepatic function. Patients in response to complete induction treatment with four monthly courses of full-dose FCR with two interim rituximab doses on day 14 of cycles 1 and 2 (oral fludarabine [40 mg/m2 per day] and oral cyclophosphamide [250 mg/m2 per day] for the first 3 days of each cycle, rituximab at 375 mg/m2 intravenously on day 0 of cycle 1 and subsequently at 500 mg/m2 on day 14 of cycle 1, days 1 and 14 of cycle 2, and day 1 of cycles 3 and 4) were eligible for randomisation. Recovery from FCR toxicity and patient willingness to continue the trial were mandatory. We randomly assigned (1:1) patients to either receive intravenous rituximab (500 mg/m2) every 8 weeks for up to 2 years or undergo observation, with a central computer-generated randomisation list using randomly permuted blocks of variable sizes. Randomisation was stratified by IGHV mutational status, the presence or absence of del(11q), and response level to induction treatment. The primary endpoint was progression-free survival, with the objective to assess the superiority of rituximab maintenance relative to observation. The final analysis was done in the intention-to-treat population. Safety was analysed in all patients who received at least one dose of study drug in the rituximab group and in all patients in the observation group. This trial is closed to accrual whilst continuing patient follow-up. The study is registered with ClinicalTrials.gov, number NCT00645606. FINDINGS Between Dec 14, 2007, and Feb 18, 2014, 542 patients were enrolled, of whom 525 started FCR induction. Between June 10, 2008, and Aug 14, 2014, 409 (78%) patients were randomly assigned to rituximab maintenance (n=202) or observation (n=207). Four (2%) patients in the rituximab group did not receive the allocated treatment (progressive disease [n=1], adverse events [n=3]). After a median follow-up of 47·7 months (IQR 30·4-65·8), median progression-free survival in the rituximab group (59·3 months, 95% CI 49·6-not estimable) was improved compared with the observation group (49·0 months, 39·9-60·5; hazard ratio 0·55, 95% CI 0·40-0·75; p=0·0002). Neutropenia and grade 3-4 infections were more common with rituximab maintenance (105 [53%] of 198 patients vs 74 [36%] of 207 patients and 38 [19%] vs 21 [10%], respectively) during the study. The most common grade 3-4 infection was lower respiratory tract infection (24 [12%] vs eight [4%]). The incidence of second cancers, except basal cell carcinoma, was similar in both groups (29 [15%] vs 23 [11%]). Deaths were related to adverse events for 23 (11%) patients in the rituximab group and 16 (8%) in the observation group. INTERPRETATION 2-year maintenance rituximab in selected elderly patients improves progression-free survival and shows an acceptable safety profile. Immunotherapy maintenance strategy is a relevant option in front-line treatment of chronic lymphocytic leukaemia, even in the age of targeted therapy. FUNDING French National Cancer Institute (INCa), Roche, Chugai.
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Affiliation(s)
- Caroline Dartigeas
- Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Tours, France.
| | - Eric Van Den Neste
- Cancérologie et Hématologie, Cliniques Universitaires UCL Saint-Luc, Brussels, Belgium
| | | | - Hervé Maisonneuve
- Médecine Interne Onco-Hématologie, Centre Hospitalier Départemental de Vendée, La Roche Sur Yon, France
| | | | - Marie-Sarah Dilhuydy
- Hématologie Clinique et Thérapie Cellulaire, Hôpital Haut Lévêque, CHU Bordeaux, Pessac, France
| | - Sophie De Guibert
- Hématologie Clinique, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Stéphane Leprêtre
- Département d'Hématologie, Centre Henri Becquerel, Inserm U1245, Université de Normandie, Rouen, France
| | - Marie C Béné
- Service d'Hématologie Biologique, CHU Nantes, Nantes, France
| | - Florence Nguyen-Khac
- Unité de Cytogénétique Hématologique, Hôpital Pitié-Salpêtrière, AP-HP, Inserm U1138, Université Paris 6, Paris, France
| | - Rémi Letestu
- Service d'Hématologie Biologique, Hôpital Avicenne, AP-HP, Bobigny, France
| | | | - Philippe Rodon
- Onco-Hématologie, Centre Hospitalier de Blois, Blois, France
| | | | - Jean-Pierre Vilque
- Institut d'Hématologie, Hôpital François Baclesse, CHU Caen, Caen, France
| | - Olivier Tournilhac
- Hématologie Clinique et Thérapie Cellulaire, Hôpital d'Estaing, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Béatrice Mahé
- Hématologie Clinique, Hôpital Hôtel Dieu, CHU Nantes, Nantes, France
| | - Kamel Laribi
- Hématologie, Centre Hospitalier du Mans, Le Mans, France
| | - Anne-Sophie Michallet
- Hématologie Clinique, Hospices Civils de Lyon, CHU Lyon, Hématologie, Centre Léon Bérard, Lyon, France
| | - Alain Delmer
- Hématologie Clinique, Hôpital Robert Debré, CHU Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Pierre Feugier
- Hématologie, Hôpitaux de Brabois, CHU Nancy, Inserm U954, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Vincent Lévy
- URC/CRC, Groupe Hospitalier Paris Seine Saint Denis, AP-HP, Inserm U1153, Université Paris 13, Bobigny, France
| | - Roselyne Delépine
- French Innovative Leukemia Organization FILO, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Philippe Colombat
- Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Tours, France
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Soe ZN, Allsup D. The use of ofatumumab in the treatment of B-cell malignancies. Future Oncol 2017; 13:2611-2628. [DOI: 10.2217/fon-2017-0275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Ofatumumab has been extensively studied in the treatment of B-cell malignancies. Currently, it has been approved for the treatment of chronic lymphocytic leukemia in a number of different situations. However, there is still no compelling evidence confirming the superiority of ofatumumab over rituximab in vivo. In this article, we summarize the currently available clinical data supporting the use of ofatumumab in the treatment of B-cell malignancies. The clinical studies were searched from clinicaltrials.gov with the key words ofatumumab, HuMax-CD20. Out of 115 trials available, studies for B-cell malignancies were selected, followed by selection of completed studies with results and active ongoing studies. The results from completed studies were thoroughly analyzed and active ongoing studies were listed in tables.
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Affiliation(s)
- Zar Ni Soe
- Department of Haematology, Hull & East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, England, UK
| | - David Allsup
- Department of Haematology, Hull & East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, England, UK
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Seymour EK, Schiffer CA, de Souza JA. Challenges in the Clinical Application of the American Society of Clinical Oncology Value Framework: A Medicare Cost-Benefit Analysis in Chronic Lymphocytic Leukemia. J Oncol Pract 2017; 13:e1002-e1011. [PMID: 29144866 PMCID: PMC9797243 DOI: 10.1200/jop.2017.024778] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE The ASCO Value Framework calculates the value of cancer therapies. Given costly novel therapeutics for chronic lymphocytic leukemia, we used the framework to compare net health benefit (NHB) and cost within Medicare of all regimens listed in the National Comprehensive Cancer Network (NCCN) guidelines. METHODS The current NCCN guidelines for chronic lymphocytic leukemia were reviewed. All referenced studies were screened, and only randomized controlled prospective trials were included. The revised ASCO Value Framework was used to calculate NHB. Medicare drug pricing was used to calculate the cost of therapies. RESULTS Forty-nine studies were screened. The following observations were made: only 10 studies (20%) could be evaluated; when comparing regimens studied against the same control arm, ranking NHB scores were comparable to their preference in guidelines; NHB scores varied depending on which variables were used, and there were no clinically validated thresholds for low or high values; treatment-related deaths were not weighted in the toxicity scores; and six of the 10 studies used less potent control arms, ranked as the least-preferred NCCN-recommended regimens. CONCLUSION The ASCO Value Framework is an important initial step to quantify value of therapies. Essential limitations include the lack of clinically relevant validated thresholds for NHB scores and lack of incorporation of grade 5 toxicities/treatment-related mortality into its methodology. To optimize its application for clinical practice, we urge investigators/sponsors to incorporate and report the required variables to calculate the NHB of regimens and encourage trials with stronger comparator arms to properly quantify the relative value of therapies.
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Affiliation(s)
- Erlene K. Seymour
- Karmanos Cancer Institute/Wayne State University, Detroit, MI; and The University of Chicago, Chicago, IL,Corresponding author: Erlene K. Seymour, MD, Karmanos Cancer Institute/Wayne State University, 4100 John R, HW04HO, Detroit, MI, 48201; e-mail:
| | - Charles A. Schiffer
- Karmanos Cancer Institute/Wayne State University, Detroit, MI; and The University of Chicago, Chicago, IL
| | - Jonas A. de Souza
- Karmanos Cancer Institute/Wayne State University, Detroit, MI; and The University of Chicago, Chicago, IL
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Abstract
The last several years have witnessed a paradigm shift in the management of patients with chronic lymphocytic leukemia (CLL). The course of this very heterogeneous disease, traditionally treated with chemotherapeutic agents usually in combination with rituximab, typically has been characterized by remissions and relapses, and survival times vary greatly, depending on intrinsic biological attributes of the leukemia. The developments of the last few years have been transformative, ushering in an era of novel, molecularly targeted therapies, made possible by extensive efforts to elucidate the biology of the disease that predated the new targeted drugs. Thus, successful therapeutic targeting of the B-cell receptor signaling pathway and of the Bcl-2 anti-apoptotic protein with small molecules has now made chemotherapy-free approaches possible, hopefully mitigating the risk of development of therapy-related myeloid neoplasms and making eventual cure of CLL with the use of optimal drug combinations a realistic goal. Most importantly, these therapies have demonstrated unprecedented efficacy in patients with deletion 17p/TP53 mutation, a subset that historically has been very difficult to treat. However, as we gain more experience with the newer agents, unique safety concerns and resistance mechanisms have emerged, as has the issue of cost, as these expensive drugs are currently administered indefinitely. Accordingly, novel laboratory-based strategies and clinical trial designs are being explored to address these issues. The availability of whole exome/genome sequencing has given us profound insights into the mutational landscape of CLL. In this article, we highlight some of the most impactful advances since this topic was last reviewed in this journal.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Varsha Gandhi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chanan-Khan AA, Zaritskey A, Egyed M, Vokurka S, Semochkin S, Schuh A, Kassis J, Simpson D, Zhang J, Purse B, Foà R. Lenalidomide maintenance therapy in previously treated chronic lymphocytic leukaemia (CONTINUUM): a randomised, double-blind, placebo-controlled, phase 3 trial. LANCET HAEMATOLOGY 2017; 4:e534-e543. [PMID: 28958469 DOI: 10.1016/s2352-3026(17)30168-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The efficacy and safety of lenalidomide as maintenance therapy after chemotherapy-based second-line therapy in patients with chronic lymphocytic leukaemia is unknown. Although kinase inhibitors can improve outcomes for some patients with relapsed and refractory disease, not all patients have access to these novel drugs. In this study, we aimed to assess the efficacy and safety of lenalidomide as maintenance therapy in patients with previously treated chronic lymphocytic leukaemia. METHODS This randomised, double-blind, placebo-controlled, phase 3 trial (CONTINUUM) was done at 111 hospitals, medical centres, and clinics in 21 countries. Patients were eligible if they had chronic lymphocytic leukaemia; were aged 18 years or older; had been treated with two lines of therapy (with at least a partial response after second-line therapy); had received a purine analogue, bendamustine, anti-CD20 antibody, chlorambucil, or alemtuzumab as first-line or second-line treatment; and had an Eastern Cooperative Oncology Group performance score of 0-2. Eligible patients were randomly assigned (1:1) by an interactive voice-response system to receive either oral lenalidomide (2·5 mg/day) or matching oral placebo capsules (2·5 mg/day) for 28-day cycles, until disease progression or unacceptable toxicity. Lenalidomide dose escalation (to 5 mg or 10 mg per day) was permitted if the drug was well tolerated. Patients, investigators, and those completing data analyses were masked to treatment allocation. Randomisation was stratified by age, response to second-line therapy, and prognostic factors. Co-primary endpoints were progression-free survival and overall survival; the primary endpoint was later changed to overall survival after the data cutoff for this analysis. Secondary endpoints were time from randomisation to second disease progression or death (PFS2),32 tumour response (improvement in response and duration of response), safety, and health-related quality of life (HRQoL). Efficacy analyses were done in the intention-to-treat population. Safety was analysed in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT00774345, and is closed to accrual, but follow-up is ongoing. FINDINGS Between Feb 16, 2009 and Sept 29, 2015, 314 patients with chronic lymphocytic leukaemia were enrolled and randomly assigned to receive either lenalidomide (n=160) or placebo (n=154). With a median follow-up of 31·5 months (IQR 18·9-50·8), there was no significant difference in overall survival between the lenalidomide and the placebo groups (median 70·4 months, 95% CI 57·5-not estimable [NE] vs NE, 95% CI 62·8-NE; hazard ratio [HR] 0·96, 95% CI 0·63-1·48; p=0·86). Progression-free survival was significantly longer in the lenalidomide group (median 33·9 months, 95% CI 25·5-52·5) than in the placebo group (9·2 months, 7·4-13·6; HR 0·40, 95% CI 0·29-0·55; p<0·0001). PFS2 was significantly longer in the lenalidomide group than in the placebo group (median 57·5 months [47·7-NE] vs 32·7 months [26·4-49·0]; HR 0·46, 95% CI 0·29-0·70; p<0·01). Improved responses from baseline were observed in ten (6%) of 160 lenalidomide-treated patients versus four (3%) of 154 placebo-treated patients (p=0·12). Median time to improved response was 12·2 weeks (IQR 7·2-22·5) in the lenalidomide group versus 76·3 weeks (20·2-182·6) in the placebo group. Duration of improved response was not estimable in either group (95% CI 22·9-NE in the lenalidomide group vs NE-NE for placebo). There were no clinically meaningful differences in HRQoL between lenalidomide-treated patients and placebo-treated patients, as measured by FACT-Leu and EQ-5D, during maintenance treatment. In the safety population, the most common grade 3 or 4 adverse events included neutropenia (94 [60%] of 157 patients in the lenalidomide group vs 35 [23%] of 154 patients in the placebo group), thrombocytopenia (26 [17%] vs ten [6%]), and diarrhoea (13 [8%] vs one [<1%]). There were five fatal adverse events (three [2%] patients in the lenalidomide group and two [1%] patients in the placebo group). INTERPRETATION Lenalidomide might delay time to subsequent therapy and does not adversely affect response to subsequent therapy. Chemoimmunotherapy followed by lenalidomide maintenance could be an effective treatment option for patients with chronic lymphocytic leukaemia who do not have access to kinase inhibitors. FUNDING Celgene Corporation.
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Affiliation(s)
| | - Andrey Zaritskey
- Institute of Hematology, Federal Almazov North-West Medical Research Centre, St Petersburg, Russia
| | - Miklos Egyed
- Department of Internal Medicine, Kaposi Mór Teaching Hospital, Kaspovár, Hungary
| | - Samuel Vokurka
- Department of Haemato-oncology, University Hospital Pilsen, Plzeň, Czech Republic
| | - Sergey Semochkin
- Division of Oncology and Hematology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anna Schuh
- Department of Oncology, University of Oxford, Oxford, UK
| | - Jeannine Kassis
- Department of Hematology, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - David Simpson
- Department of Haematology, North Shore Hospital, Auckland, New Zealand
| | | | | | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, Sapienza University, Rome, Italy
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Lenalidomide maintenance in high risk chronic lymphocytic leukaemia: practice changing study or hypothesis generating approach? LANCET HAEMATOLOGY 2017; 4:e455-e456. [PMID: 28916312 DOI: 10.1016/s2352-3026(17)30178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/24/2022]
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Maintenance Therapies in Indolent Lymphomas: should Recent Data Change the Standard of Care? Curr Treat Options Oncol 2017; 18:16. [PMID: 28286923 DOI: 10.1007/s11864-017-0459-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OPINION STATEMENT The overall benefit of maintenance therapy for patients with an indolent lymphoma continues to go unanswered. A myriad of variables contribute to the lack of clear clinical guidance. First, the disease course is slow and treatment may not be required for years, requiring a long follow-up to prospectively study. Second, due to the long lag time from study initiation to conclusion, many of the induction therapies used at the onset of the study may not be favored at present, providing a conclusion that cannot be reconciled with current clinical practice. For example, bendamustine and rituximab are typically the favored initial treatment agents in follicular lymphoma, which was not true when many maintenance trials were initiated. Third, several studies' inclusion criteria allow for patient enrollment at both initial diagnosis as well as at disease recurrence. In some studies, patients who are asymptomatic are started on therapy, counter to the accepted watch and wait approach. This contributes to the difficulty of generalizing results. The question of the benefit of maintenance therapy has been studied enough, and there may not be a smoking gun in the foreseeable future. However, what does hold promise is focusing on the patients with minimum residual disease after conclusion of chemotherapy. This may be a population that could receive benefit from a prolonged treatment approach. In the meantime, maintenance therapy should not be used in all patients, and the rationale for use should be data-driven, as well as an assessment of a patient's potential intolerability of cytotoxic chemotherapy.
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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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Golay J. Direct targeting of cancer cells with antibodies: What can we learn from the successes and failure of unconjugated antibodies for lymphoid neoplasias? J Autoimmun 2017; 85:6-19. [PMID: 28666691 DOI: 10.1016/j.jaut.2017.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/11/2017] [Indexed: 12/26/2022]
Abstract
Following approval in 1997 of the anti-CD20 antibody rituximab for the treatment of B-NHL and CLL, many other unconjugated IgG1 MAbs have been tested in pre-clinical and clinical trials for the treatment of lymphoid neoplasms. Relatively few have been approved however and these are directed against a limited number of target antigens (CD20, CD52, CCR4, CD38, CD319). We review here the known biological properties of these antibodies and discuss which factors may have led to their success or may, on the contrary, limit their clinical application. Common factors of the approved MAbs are that the target antigen is expressed at relatively high levels on the neoplastic targets and their mechanism of action is mostly immune-mediated. Indeed most of these MAbs induce ADCC and phagocytosis by macrophages, and many also activate complement, leading to target cell lysis. In contrast direct cell death induction is not a common feature but may enhance efficacy in some cases. Interestingly, a key factor for the success of several MAbs appears to be their capacity to skew immunity towards an anti-tumour mode, by inhibiting/depleting suppressor cells and/or activating immune cells within the microenvironment, independently of FcγRs. We also expose here some of the strategies employed by industry to expand the clinical use of these molecules beyond their original indication. Interestingly, due to the central role of lymphocytes in the control of the immune response, several of the antibodies are now successfully used to treat many different autoimmune diseases and have also been formally approved for some of these new indications. There is little doubt that this trend will continue and that the precise mechanisms of therapeutic MAbs will be further dissected and better understood in the context of both tumour immunology and autoimmunity.
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Affiliation(s)
- Josée Golay
- Center of Cellular Therapy "G. Lanzani", USC Haematology, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Via Garibaldi 11-13, 24128, Bergamo, Italy.
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Wu Y, Wang Y, Gu Y, Xia J, Kong X, Qian Q, Hong Y. Safety and efficacy of Ofatumumab in chronic lymphocytic leukemia: a systematic review and meta-analysis. Hematology 2017; 22:578-584. [PMID: 28580841 DOI: 10.1080/10245332.2017.1333974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Yougen Wu
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yang Wang
- Department of General Psychiatry, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Yuting Gu
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Ju Xia
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Xiaoyang Kong
- Department of Hematology, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Qingqing Qian
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yang Hong
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
- Department of Osteology, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
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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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Butler LA, Tam CS, Seymour JF. Dancing partners at the ball: Rational selection of next generation anti-CD20 antibodies for combination therapy of chronic lymphocytic leukemia in the novel agents era. Blood Rev 2017; 31:318-327. [PMID: 28499646 DOI: 10.1016/j.blre.2017.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023]
Abstract
The anti-CD20 antibodies represent a major advancement in the therapeutic options available for chronic lymphocytic leukemia. The addition of rituximab, ofatumumab and obinutuzumab to various chemotherapy regimens has led to considerable improvements in both response and survival. Ocaratuzumab, veltuzumab and ublituximab are currently being explored within the trial setting. We review the current status of these antibodies, and discuss how their mechanisms of action may impact on the choice of combinations with novel small molecule agents.
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Affiliation(s)
- L A Butler
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - C S Tam
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia
| | - J F Seymour
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia.
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68
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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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Chaoui D, Choquet S, Sanhes L, Mahé B, Hacini M, Fitoussi O, Arkam Y, Orfeuvre H, Dilhuydy MS, Barry M, Jourdan E, Dreyfus B, Tempescul A, Leprêtre S, Bardet A, Leconte P, Maynadié M, Delmer A. Relapsed chronic lymphocytic leukemia retreated with rituximab: interim results of the PERLE study. Leuk Lymphoma 2017; 58:1366-1375. [DOI: 10.1080/10428194.2016.1243673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Driss Chaoui
- Hématologie, Centre hospitalier Victor Dupouy, Argenteuil, France
| | | | | | | | - Maya Hacini
- Hématologie, Centre hospitalier de Chambéry, Chambéry, France
| | | | - Yazid Arkam
- Hématologie, Hôpital Emile Muller, Mulhouse, France
| | - Hubert Orfeuvre
- Hématologie, Centre hospitalier de Fleyriat, Bourg en Bresse, France
| | | | - Marly Barry
- Hématologie, Centre hospitalier du Dr Duchenne, Boulogne sur Mer, France
| | | | | | | | | | - Aurélie Bardet
- Medical Affairs, Roche France, Boulogne-Billancourt, France
| | - Pierre Leconte
- Medical Affairs, Roche France, Boulogne-Billancourt, France
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Feng JJ, Ontaneda D. Treating primary-progressive multiple sclerosis: potential of ocrelizumab and review of B-cell therapies. Degener Neurol Neuromuscul Dis 2017; 7:31-45. [PMID: 30050376 PMCID: PMC6053100 DOI: 10.2147/dnnd.s100096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Multiple sclerosis (MS) therapy has evolved rapidly with an increased availability of several immunomodulating therapies over the past two decades. Disease-modifying therapies have proven to be effective in treating relapse-remitting MS (RRMS). However, clinical trials involving some of the same agents for secondary-progressive and primary-progressive MS (SPMS and PPMS) have been largely negative. The pathogenesis of progressive MS remains unclear, but B-cells may play a significant role in chronic compartmentalized inflammation, likely contributing to disease progression. Biologics targeted at B-cells, such as rituximab, are effective in treating RRMS. Ocrelizumab is a humanized monoclonal antibody to CD20+ B-cells that has shown positive results in PPMS with a significant reduction in disease progression. This review aims to discuss in detail the involvement of B-cells in MS pathogenesis, current progress of currently available and investigational biologics, with focus on ocrelizumab, and future prospects for B-cell therapy in PPMS.
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Affiliation(s)
| | - Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Cleveland Clinic, Cleveland, OH, USA,
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Tees MT, Flinn IW. Chronic lymphocytic leukemia and small lymphocytic lymphoma: two faces of the same disease. Expert Rev Hematol 2016; 10:137-146. [PMID: 27936980 DOI: 10.1080/17474086.2017.1270203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered indolent lymphocytic malignancies, more often requiring active surveillance rather than intervention. Despite the indolent nature of CLL/SLL, treatment is likely indicated in a patients' lifetime. Recent changes in the therapeutic landscape have created more options to the clinician. Areas covered: The authors provide a broad assessment of the current state of disease, including the work-up, prognostic features, and mutational aspects of the disease that should be acknowledged when developing a rational treatment plan. Key studies, guideline recommendations, and expert analysis are used to create this update on CLL/SLL. Expert commentary: The recent pace of treatment additions in CLL/SLL is a welcome addition. Moving forward, it is anticipated that treatment modalities will continue to evolve, leading to additional management options that truly would define CLL/SLL as a chronic disease.
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Affiliation(s)
- Michael T Tees
- a Colorado Blood Cancer Institute , Denver , CO , USA.,c Sarah Cannon Blood Cancer Network , Nashville , TN , USA
| | - Ian W Flinn
- b Tennesee Oncology , Nashville , TN , USA.,c Sarah Cannon Blood Cancer Network , Nashville , TN , USA
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72
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Korycka-Wołowiec A, Wołowiec D, Robak T. The safety profile of monoclonal antibodies for chronic lymphocytic leukemia. Expert Opin Drug Saf 2016; 16:185-201. [PMID: 27880061 DOI: 10.1080/14740338.2017.1264387] [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: 12/22/2022]
Abstract
INTRODUCTION Monoclonal antibodies (MoAbs), non-chemotherapeutic agents targeting the antigens present on chronic lymphocytic leukemia (CLL) lymphocytes, are being implemented increasingly more often as treatment options. Areas covered: This article reviews the similarities and differences in the structure, mechanism of action, efficacy and safety profile of commercially-available MoAbs and prevents new agents potentially useful for CLL treatment. Publications in English before June 2016 were surveyed on the MEDLINE database for articles. Proceedings of the American Society of Hematology held during the last five years were also included. Expert opinion: MoAbs, especially those targeting CD20, are highly effective biological options for first-line and salvage treatment of CLL, particularly in chemoimmunotherapy, and possibly also as maintenance therapy. Treatment with MoAbs is associated with reduced risk of such adverse events as cytopenias, infections and secondary neoplasias and is generally well tolerated. Depending on antibody type, the most common adverse events are usually transient and limited to grade 1 and 2 infusion-related reactions. In addition to commercially available MoAbs, several other antibodies exist which are targeted against different antigens studied in the clinical trials.
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Affiliation(s)
| | - Dariusz Wołowiec
- b Department of Hematology , Medical University of Wroclaw , Wroclaw , Poland
| | - Tadeusz Robak
- a Department of Hematology Medical , University of Lodz , Lodz , Poland
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Al-Sawaf O, Fischer K, Herling CD, Ritgen M, Böttcher S, Bahlo J, Elter T, Stilgenbauer S, Eichhorst BF, Busch R, Elberskirch U, Abenhardt W, Kneba M, Hallek M, Wendtner CM. Alemtuzumab consolidation in chronic lymphocytic leukaemia: a phase I/II multicentre trial. Eur J Haematol 2016; 98:254-262. [PMID: 27862308 DOI: 10.1111/ejh.12825] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Despite high rates of long-lasting remissions in patients with chronic lymphocytic leukaemia (CLL) treated with chemoimmunotherapy, none of the current therapeutic approaches is curative with the exception of allogeneic transplantation. One strategy to extend progression-free survival and long-term survival might be the establishment of consolidation therapies. METHODS In this trial, patients with complete or partial second remission after fludarabine-based treatment received consolidation therapy with alemtuzumab. The aim of this phase I/II trial was to determine the maximal tolerable dose (MTD) of alemtuzumab consolidation and to evaluate safety and efficacy in patients who responded to second-line fludarabine-based treatment. Thirteen patients in complete (CR) or partial remission (PR) received alemtuzumab dose escalation starting with 10 mg intravenously (iv) once weekly for 8 wk and increasing in 10-mg intervals per dose level. RESULTS The main dose-limiting toxicities (DLTs) were infectious complications, and the MTD was determined at 10 mg. After alemtuzumab consolidation, seven of 13 patients (53%) were in CR, and four of these patients (30.7%) achieved minimal residual disease (MRD) negativity (<1 × 10E-4). At a median follow-up of 71.5 months, four patients were progression-free, with a median progression-free survival (PFS) of 28.5 months after the end of second-line treatment. CONCLUSION The results provide a safe and efficient schedule with weekly intravenous application of 10 mg of alemtuzumab as a consolidation regime in patients with CLL.
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Affiliation(s)
- Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Carmen D Herling
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sebastian Böttcher
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jasmin Bahlo
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Thomas Elter
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | | | - Barbara F Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Raymonde Busch
- Institute for Medical Statistic and Epidemiology, Technical University, Munich, Germany
| | - Ute Elberskirch
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | | | - Michael Kneba
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Clemens-Martin Wendtner
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany.,Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, Klinikum Schwabing, Munich, Germany
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74
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Mozas P, Delgado J. [Advances in the treatment of chronic lymphocytic leukaemia]. Med Clin (Barc) 2016; 147:447-454. [PMID: 27431885 DOI: 10.1016/j.medcli.2016.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
Chronic lymphocytic leukemia (CLL), a proliferation of mature B cells, is one of the most prevalent haematological malignancies. Progress has been made in its treatment during the last few decades, and chemoimmunotherapy based on fludarabine, cyclophosphamide and rituximab is considered the treatment of choice for patients with standard-risk CLL and good performance status. However, due to the characterization of high-risk biological subgroups and its presentation in elderly patients and/or with comorbidities, targeted therapies, such as B-cell receptor inhibitors, have been developed and approved during the last few years. The current review examines traditional therapeutic strategies and focuses on new small molecules that already represent promising elements of the CLL treatment landscape.
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Affiliation(s)
- Pablo Mozas
- Servicio de Hematología, Instituto Clínico de Enfermedades Hemato-Oncológicas, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Julio Delgado
- Servicio de Hematología, Instituto Clínico de Enfermedades Hemato-Oncológicas, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España.
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Jacobs RW, Awan FT, Leslie LA, Usmani SZ, Ghosh N. The shrinking role of chemotherapy in the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:1177-1187. [DOI: 10.1080/17474086.2016.1254545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Robak T, Warzocha K, Govind Babu K, Kulyaba Y, Kuliczkowski K, Abdulkadyrov K, Loscertales J, Kryachok I, Kłoczko J, Rekhtman G, Homenda W, Błoński JZ, McKeown A, Chang CN, Bal V, Lisby S, Gupta IV, Grosicki S. Health-related quality of life and patient-reported outcomes of ofatumumab plus fludarabine and cyclophosphamide versus fludarabine and cyclophosphamide in the COMPLEMENT 2 trial of patients with relapsed CLL. Leuk Lymphoma 2016; 58:1598-1606. [DOI: 10.1080/10428194.2016.1253837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Łódź, Copernicus Memorial Hospital, Łódź, Poland
| | - Krzysztof Warzocha
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - K. Govind Babu
- Kidwai Memorial Institute of Oncology, Bangalore, India
- HCG Curie Centre of Oncology, Bangalore, India
| | - Yaroslav Kulyaba
- Makiivka City Hospital No. 2 of Donetsk Region, Makiivka, Ukraine
| | | | - Kudrat Abdulkadyrov
- Russian Research Institute of Hematology and Transfusiology, St. Petersburg, Russian Federation
| | | | - Iryna Kryachok
- Oncohematology Department, National Cancer Institute, Kiev, Ukraine
| | | | | | - Wojciech Homenda
- Department of Hematology, Janusz Korczak Hospital, Słupsk, Poland
| | - Jerzy Z. Błoński
- Department of Hematology, Medical University of Łódź, Copernicus Memorial Hospital, Łódź, Poland
| | - Astrid McKeown
- Novartis Pharmaceuticals Corporation, Uxbridge, United Kingdom
| | - Chai-Ni Chang
- Novartis Pharmaceuticals Corporation, Research Triangle Park, NC, USA
| | - Vasudha Bal
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Ira V. Gupta
- Novartis Pharmaceuticals Corporation, King of Prussia, PA, USA
| | - Sebastian Grosicki
- Department of Cancer Prevention, Faculty of Public Health, Medical University of Silesia, Katowice, Poland
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Robak T, Warzocha K, Govind Babu K, Kulyaba Y, Kuliczkowski K, Abdulkadyrov K, Loscertales J, Kryachok I, Kłoczko J, Rekhtman G, Homenda W, Błoński JZ, McKeown A, Gorczyca MM, Carey JL, Chang CN, Lisby S, Gupta IV, Grosicki S. Ofatumumab plus fludarabine and cyclophosphamide in relapsed chronic lymphocytic leukemia: results from the COMPLEMENT 2 trial. Leuk Lymphoma 2016; 58:1084-1093. [PMID: 27731748 DOI: 10.1080/10428194.2016.1233536] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In this multicenter, open-label, phase III study, patients with relapsed chronic lymphocytic leukemia (CLL) were randomized (1:1) to receive ofatumumab plus fludarabine and cyclophosphamide (OFA + FC) or FC alone; the primary endpoint being progression-free survival (PFS) assessed by an independent review committee (IRC). Between March 2009 and January 2012, 365 patients were randomized (OFA + FC: n = 183; FC: n = 182). Median IRC-assessed PFS was 28.9 months with OFA + FC versus 18.8 months with FC (hazard ratio = 0.67; 95% confidence interval, 0.51-0.88; p = .0032). Grade ≥3 adverse events (≤60 days after last dose) were reported in 134 (74%) OFA + FC-treated patients compared with 123 (69%) FC-treated patients. Of these, neutropenia was the most common (89 [49%] vs. 64 [36%]). OFA + FC improved PFS with manageable safety for patients with relapsed CLL compared with FC alone, thus providing an alternative treatment option for patients with relapsed CLL. TRIAL REGISTRATION www.clinicaltrials.gov (NCT00824265).
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Affiliation(s)
- Tadeusz Robak
- a Department of Hematology , Medical University of Lodz and Copernicus Memorial Hospital , Lodz , Poland
| | - Krzysztof Warzocha
- b Department of Hematology , Institute of Hematology and Transfusion Medicine , Warsaw , Poland
| | - K Govind Babu
- c Kidwai Memorial Institute of Oncology , Bangalore , India.,d HCG Curie Centre of Oncology , Bangalore , India
| | - Yaroslav Kulyaba
- e Makiivka City Hospital #2 of Donetsk Region , Makiivka , Ukraine
| | | | - Kudrat Abdulkadyrov
- g Russian Research Institute of Hematology and Transfusiology , St. Petersburg , Russia
| | | | - Iryna Kryachok
- i Oncohematology Department , National Cancer Institute , Kiev , Ukraine
| | | | | | - Wojciech Homenda
- l Department of Hematology , Janusz Korczak Hospital , Słupsk , Poland
| | - Jerzy Z Błoński
- a Department of Hematology , Medical University of Lodz and Copernicus Memorial Hospital , Lodz , Poland
| | | | | | | | - Chai-Ni Chang
- o Novartis, Research Triangle Park , Durham , NC , USA
| | | | | | - Sebastian Grosicki
- r Department of Cancer Prevention, Faculty of Public Heath , Medical University of Silesia , Katowice , Poland
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Flinn IW, Ruppert AS, Harwin W, Waterhouse D, Papish S, Jones JA, Hainsworth J, Byrd JC. A phase II study of two dose levels of ofatumumab induction followed by maintenance therapy in symptomatic, previously untreated chronic lymphocytic leukemia. Am J Hematol 2016; 91:1020-5. [PMID: 27387131 DOI: 10.1002/ajh.24468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
Despite the recent advances in treatment of CLL with targeted agents such as ibrutinib, availability of nonchemotherapy based therapies is desired. Given the 58% response rate (1996 NCI-WG criteria) of single agent ofatumumab in CLL refractory to fludarabine and alemtuzumab, we initiated a phase II trial examining response, safety, and progression-free survival (PFS) of ofatumumab as front-line monotherapy. Patients enrolled included untreated, symptomatic CLL patients over the age of 65 or those who were inappropriate/did not desire chemotherapy. Two cohorts were enrolled sequentially examining either 1 g (33 patients) or 2 g (44 patients) weekly for 8 weeks followed by maintenance dosing every 2 months for a total of 24 months. Patients receiving 1 g were older than those receiving 2 g, but there were no significant differences in other clinical characteristics. The best overall response rates in the 1 and 2 g patient cohorts were 72 and 89% (1996 NCI-WG criteria), respectively (54 and 68%, respectively, using 2008 IWCLL criteria). All but two responses were partial. The 24-month estimated PFS rates were 46 and 78%, respectively. Response and PFS was lower in del(17p) and del(11q) CLL patients. Differences in PFS between dose cohorts were statistically significant and remained so when adjusting for age or high-risk cytogenetics. Toxicity of this treatment was mild with only six patients not completing therapy due to toxicity. Ofatumumab induction followed by maintenance therapy in untreated CLL represents a well-tolerated and active regimen, particularly with the 2 g of ofatumumab. Am. J. Hematol. 91:1020-1025, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ian W. Flinn
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - Amy S. Ruppert
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - William Harwin
- Sarah Cannon Research Institute; Nashville Tennessee
- Florida Cancer Specialists; Ft. Myers Florida
| | - David Waterhouse
- Sarah Cannon Research Institute; Nashville Tennessee
- Oncology Hematology Care; Cincinnati Ohio
| | - Steven Papish
- Hematology-Oncology Associates of Northern NJ; Morristown New Jersey
| | - Jeffrey A. Jones
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - John Hainsworth
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - John C. Byrd
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
- Division of Medicinal Chemistry; College of Pharmacy, The Ohio State University; Columbus Ohio
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79
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Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. LANCET HAEMATOLOGY 2016; 3:e407-14. [DOI: 10.1016/s2352-3026(16)30064-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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Delgado J, Montserrat E. Maintenance therapy in chronic lymphocytic leukaemia. LANCET HAEMATOLOGY 2016; 3:e399-400. [PMID: 27570083 DOI: 10.1016/s2352-3026(16)30081-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Julio Delgado
- Department of Haematology, Institute of Haematology and Oncology, University of Barcelona, Hospital Clínic, 08036 Barcelona, Spain
| | - Emili Montserrat
- Department of Haematology, Institute of Haematology and Oncology, University of Barcelona, Hospital Clínic, 08036 Barcelona, Spain.
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81
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Tam CS. Maintenance therapy in CLL: resolving the controversy. LANCET HAEMATOLOGY 2016; 3:e304-5. [PMID: 27374461 DOI: 10.1016/s2352-3026(16)30046-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Constantine S Tam
- Haematology Department, St Vincent's Hospital, Fitzroy, VIC, Australia; Haematology Department, Peter MacCallum Cancer Center, East Melbourne, VIC, Australia; University of Melbourne, Parkville, VIC, Australia.
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82
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Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. LANCET HAEMATOLOGY 2016; 3:e317-29. [PMID: 27374465 DOI: 10.1016/s2352-3026(16)30045-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND In many patients with chronic lymphocytic leukaemia requiring treatment, induction therapy with rituximab plus chemotherapy improves outcomes compared with chemotherapy alone. In this study we aimed to investigate the potential of rituximab maintenance therapy to prolong disease control in patients who respond to rituximab-containing induction regimens. METHODS In this randomised, international, multicentre, open-label, phase 3 clinical trial, we enrolled patients who had achieved a complete response (CR), CR with incomplete bone marrow recovery (CRi), or partial response (PR) to first-line or second-line rituximab-containing chemoimmunotherapy and randomly assigned them in a 1:1 ratio (central block randomisation in the electronic case report form system) to either intravenous rituximab 375 mg/m(2) every 3 months, or observation alone, for 2 years. Stratification was by country, line of treatment, type of chemotherapy added to the rituximab backbone, and degree of remission following induction. The primary endpoint was progression-free survival. Efficacy analysis was done in the intention-to-treat population. This is the final, event-triggered analysis. Final analysis was triggered by the occurrence of 92 events. This trial is registered with ClinicalTrials.gov, number NCT01118234. FINDINGS Between April 1, 2010, and Dec 23, 2013, 134 patients were randomised to rituximab and 129 to observation alone. Median observation times were 33·4 months (IQR 25·7-42·8) for the rituximab group and 34·0 months (25·4-41·9) for the observation group. Progression-free survival was significantly longer in the rituximab maintenance group (47·0 months, IQR 28·5-incalculable) than with observation alone (35·5 months, 95% CI 25·7-46·3; hazard ratio [HR] 0·50, 95% CI 0·33-0·75, p=0·00077). The incidence of grade 3-4 haematological toxicities other than neutropenia was similar in the two treatment groups. Grade 3-4 neutropenia occurred in 28 (21%) patients in the rituximab group and 14 (11%) patients in the observation group. Apart from neutropenia, the most common grade 3-4 adverse events were upper (five vs one [1%] patient in the observation group) and lower (three [2%] vs one [1%]) respiratory tract infection, pneumonia (nine [7%] vs two [2%]), thrombopenia (four [3%] vs four [3%]), neoplasms (five [4%] vs four [3%]), and eye disorders (four [3%] vs two [2%]). The overall incidence of infections of all grades was higher among rituximab recipients (88 [66%] vs 65 [50%]). INTERPRETATION Rituximab maintenance therapy prolongs progression-free survival in patients achieving at least a PR to induction with rituximab plus chemotherapy, and the treatment is well tolerated overall. Although it is associated with an increase in infections, there is no excess in infection mortality, suggesting that remission maintenance with rituximab is an effective and safe option in the management of chronic lymphocytic leukaemia in early treatment phases. FUNDING Arbeitsgemeinschaft Medikamentöse Tumortherapie gemeinnützige GmbH (AGMT), Roche.
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Affiliation(s)
- Richard Greil
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria.
| | - Petra Obrtlíková
- First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Lukáš Smolej
- Fourth Department of Internal Medicine-Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Tomáš Kozák
- Department of Internal Medicine-Hematology, Univ Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michael Steurer
- Department of Internal Medicine V, Medical University Innsbruck, Austria
| | - Johannes Andel
- Abteilung für Innere Medizin III, Landeskrankenhaus Steyr, Austria
| | - Sonja Burgstaller
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen GmbH, Austria
| | - Eva Mikušková
- Department of Hematooncology 2, National Cancer Institute, Bratislava, Slovakia
| | - Liana Gercheva
- Clinic of Hematology, University Hospital St Marina, Varna, Bulgaria
| | - Thomas Nösslinger
- Third Medical Department for Hematology and Oncology, Hanusch Krankenhaus der Wiener Gebietskrankenkasse, Vienna, Austria
| | - Tomáš Papajík
- Department of Hemato-oncology, University Hospital, Olomouc, Czech Republic
| | - Miriam Ladická
- Department of Clinical Oncology 1, National Cancer Institute, Bratislava, Slovakia
| | | | - Mikuláš Hrubiško
- Clinic of Hematology and Transfusiology, Slovak Medical University, University Hospital Bratislava, Slovakia
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaeology, Medical University Vienna, Austria
| | - Michael Fridrik
- Department of Internal Medicine 3, Kepler Universitätsklinikum GmbH, Med Campus III, Linz, Austria
| | - Martin Pecherstorfer
- University Hospital Krems, Karl Landsteiner Private University of Health Sciences, Department of Internal Medicine 2, Krems, Austria
| | - Eva Králiková
- Department of Hematology, FNsP F D Roosevelta, Banská Bystrica, Slovakia
| | | | - Emil Spasov
- Clinic of Hematology, UMHAT St George and Medical University, Plovdiv, Bulgaria
| | - Andreas Petzer
- Innere Medizin I, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
| | | | - Julian Raynov
- Clinic of Medical Hematology, Military Medical Academy, Sofia, Bulgaria
| | - Horst Oexle
- Innere Medizin, Landeskrankenhaus Hall, Austria
| | | | - Emília Flochová
- Department of Hematology and Transfusion, University Hospital Martin, Martin, Slovakia
| | | | - Olga Stehlíková
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Michael Doubek
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Petra Altenhofer
- Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Lisa Pleyer
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Thomas Melchardt
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Anton Klingler
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | - Jiří Mayer
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Alexander Egle
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
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83
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Awan FT, Jones JA, Maddocks K, Poi M, Grever MR, Johnson A, Byrd JC, Andritsos LA. A phase 1 clinical trial of flavopiridol consolidation in chronic lymphocytic leukemia patients following chemoimmunotherapy. Ann Hematol 2016; 95:1137-43. [PMID: 27118540 DOI: 10.1007/s00277-016-2683-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/18/2016] [Indexed: 12/17/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) who receive chemoimmunotherapy and do not achieve complete remission experience significantly shortened progression-free interval (PFS). Additionally, the majority of patients treated for relapsed disease demonstrate evidence of measurable disease. Eradication of minimal residual disease (MRD) results in improved PFS and overall survival. Maintenance therapy might result in eradication of MRD and improve response duration but might be associated with an increase in incidence of infectious complications. Flavopiridol is a broad cyclin-dependent kinase (CDK) inhibitor with established safety and efficacy in patients with relapsed CLL, particularly patients with high-risk cytogenetic features. A pharmacologically derived schedule was utilized as consolidation therapy in this phase I study to assess the safety and feasibility of outpatient therapy with flavopiridol in patients with low tumor burden. Flavopiridol was administered as a 30-min loading dose of 30 mg/m(2) followed by a 4-h infusion of 30 mg/m(2) once weekly for 3 weeks every 5 weeks (1 cycle) for planned 2 cycles in ten patients. Therapy was extremely well tolerated and no patient developed acute tumor lysis syndrome. The most common toxicities were gastrointestinal. Of the patients, 22 % improved their response from a PR to CR. Eighty-eight percent experienced a reduction in tumor burden as measured by extent of bone marrow involvement including patients with del17p and complex karyotype. The study establishes the safety and efficacy of flavopiridol as consolidation therapy after chemoimmunotherapy for patients with CLL. Further evaluation is required in larger trials for the utility of CDK inhibitors as consolidation or maintenance strategies.Registration number at ClinicalTrials.gov: NCT00377104.
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Affiliation(s)
- Farrukh T Awan
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
| | - Jeffrey A Jones
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Kami Maddocks
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Ming Poi
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Michael R Grever
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Amy Johnson
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - John C Byrd
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Leslie A Andritsos
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
- Starling Loving Hall, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
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84
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The expanding spectrum of HCV-related cryoglobulinemic vasculitis: a narrative review. Clin Exp Med 2016; 16:233-42. [PMID: 26935415 DOI: 10.1007/s10238-016-0410-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/10/2016] [Indexed: 02/06/2023]
Abstract
Cryoglobulinemic vasculitis (CV) is a small-to-medium-vessel vasculitis that appears in 10-15 % of patients chronically infected with hepatitis C virus (HCV). The classic symptom triad of CV, purpura/asthenia/arthralgia, is accompanied by clinical features that include glomerulonephritis, neuropathy, interstitial pneumonitis, and cardiomyopathy, ranging in their severity from mild to life threatening. The risk of developing non-Hodgkin lymphoma is also higher. The cumulative 10-year survival rate of CV patients is significantly lower than in the age- and sex-matched general population, with death typically caused by nephropathy, malignancies, liver involvement, and severe infections. Unfailing serological stigmata include both a cryoglobulin IgM fraction with rheumatoid factor activity and decreased complement C4 levels. On peripheral B cells, the expression of the CD81 B cell receptor is reduced while that of the CD19 receptor is increased. A monoclonal B cell lymphocytosis develops in almost one-third of patients. HCV-related proteins (but not HCV-RNA genomic sequences) can be detected on biopsy samples by immunofluorescence and immunohistochemistry and involve the vessel lumen, vessel walls, and the perivascular spaces of the skin, kidney, and peripheral nerves, supporting the pathogenetic role of HCV in the onset of a widespread microvasculitis. Based on the demonstration of HCV infection in the large majority of CV patients, a therapeutic regimen consisting of once-weekly pegylated interferon-α and the daily administration of ribavirin results in a sustained virologic response in ~50 % of patients. In those with refractory and relapsing disease, addition of the anti-CD20 monoclonal antibody rituximab has significantly increased the overall response rates. The extension to CV of latest-generation direct-acting antivirals, strikingly successful in non-CV HCV-positive patients, has yielded high complete response rates according to the few studies published thus far.
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85
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Rai KR, Jain P. Chronic lymphocytic leukemia (CLL)-Then and now. Am J Hematol 2016; 91:330-40. [PMID: 26690614 DOI: 10.1002/ajh.24282] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 12/27/2022]
Abstract
The field of chronic lymphocytic leukemia (CLL) has witnessed considerable change since the time clinical staging was introduced in clinical practice in 1975. Over the years, the prognostication in CLL has expanded with the addition in late 90s of mutational status of variable region of immunoglobulin heavy chain (IGHV), and chromosomal analyses using fluorescent in situ hybridization (FISH). More recently, stereotypy of BCR (B cell receptor) and whole exome sequencing (WES) based discovery of specific mutations such as NOTCH1, TP53, SF3B1, XPO-1, BIRC3, ATM, and RPS15 further refined the current prognostication system in CLL. In therapy, the field of CLL has seen major changes from oral chlorambucil and steroids prior to 1980s, to chemo-immunotherapy (CIT) with fludarabine, cyclophosphamide, rituximab (FCR) to the orally administered targeted therapeutic agents inhibiting kinases in the B cell receptor (BCR) signaling pathway such as Ibrutinib (BTK inhibitor) and Idelalisib (p110 PI3Kδ inhibitor) and novel anti-CD20 mAb's (monoclonal antibodies) such as obinutuzumab. This progress is continuing and other targeted therapeutics such as Bcl2 antagonists (Venetoclax or ABT-199) and finally chimeric antigen receptor against T cells (CART) are in the process of being developed. This review is an attempt to summarize the major benchmarks in the prognostication and in the therapy of CLL. The topic allocated to us by Dr Ayalew Tefferi and Dr Carlo Brugnara is very appropriate to reminisce what our understanding of chronic lymphocytic leukemia (CLL) was in 1976 and how rapidly have the advances occurring in this field affected the patients with CLL.
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Affiliation(s)
- Kanti R. Rai
- Division of Hematology-Oncology, NSLIJ-Hofstra School of Medicine, Long Island Jewish Medical Center; CLL Research and Treatment Program; New Hyde Park New York
| | - Preetesh Jain
- Department of Internal Medicine; University of Texas Medical School at Houston; Texas
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86
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Laurenti L, Innocenti I, Autore F, Sica S, Efremov DG. New developments in the management of chronic lymphocytic leukemia: role of ofatumumab. Onco Targets Ther 2016; 9:421-9. [PMID: 26855591 PMCID: PMC4725726 DOI: 10.2147/ott.s72845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Ofatumumab is one of the three anti-CD20 monoclonal antibodies currently available for the treatment of chronic lymphocytic leukemia (CLL). The US Food and Drug Administration (FDA) approved the use of ofatumumab in patients with CLL refractory to fludarabine and alemtuzumab in 2009, and the European Medicines Agency (EMA) granted approval for the same indication in 2010. Subsequent positive results of ofatumumab in combination with chlorambucil in treatment-naïve patients led the FDA in April 2014 to approve the use of this combination for first-line treatment of patients with CLL for whom fludarabine-based therapy is considered inappropriate. Later that year, the EMA approved the use of ofatumumab in combination with chlorambucil or bendamustine for the same indication. Ofatumumab has also shown potential as maintenance therapy for patients with relapsed CLL; an application to broaden the label for ofatumumab as maintenance therapy was submitted earlier this year to the EMA and FDA. Finally, ofatumumab has shown promising activity in combination with ibrutinib or idelalisib in relapsed/refractory CLL patients; combinations of ofatumumab with B-cell-receptor pathway inhibitors could represent another potential use of this antibody in the near future.
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Affiliation(s)
- Luca Laurenti
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Idanna Innocenti
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Autore
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Sica
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Dimitar G Efremov
- Molecular Hematology, International Centre for Genetic Engineering and Biotechnology, Monterotondo, Italy
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87
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Korycka-Wołowiec A, Wołowiec D, Robak T. Ofatumumab for treating chronic lymphocytic leukemia: a safety profile. Expert Opin Drug Saf 2015; 14:1945-59. [DOI: 10.1517/14740338.2015.1113253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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88
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Wiestner A. PROLONGing remissions in patients with CLL. Lancet Oncol 2015; 16:1282-4. [PMID: 26377301 DOI: 10.1016/s1470-2045(15)00219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Adrian Wiestner
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20817, USA.
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