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Al-Sawaf O, Zhang C, Jin HY, Robrecht S, Choi Y, Balasubramanian S, Kotak A, Chang YM, Fink AM, Tausch E, Schneider C, Ritgen M, Kreuzer KA, Chyla B, Paulson JN, Pallasch CP, Frenzel LP, Peifer M, Eichhorst B, Stilgenbauer S, Jiang Y, Hallek M, Fischer K. Transcriptomic profiles and 5-year results from the randomized CLL14 study of venetoclax plus obinutuzumab versus chlorambucil plus obinutuzumab in chronic lymphocytic leukemia. Nat Commun 2023; 14:2147. [PMID: 37072421 PMCID: PMC10113251 DOI: 10.1038/s41467-023-37648-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/24/2023] [Indexed: 04/20/2023] Open
Abstract
Data on long-term outcomes and biological drivers associated with depth of remission after BCL2 inhibition by venetoclax in the treatment of chronic lymphocytic leukemia (CLL) are limited. In this open-label parallel-group phase-3 study, 432 patients with previously untreated CLL were randomized (1:1) to receive either 1-year venetoclax-obinutuzumab (Ven-Obi, 216 patients) or chlorambucil-Obi (Clb-Obi, 216 patients) therapy (NCT02242942). The primary endpoint was investigator-assessed progression-free survival (PFS); secondary endpoints included minimal residual disease (MRD) and overall survival. RNA sequencing of CD19-enriched blood was conducted for exploratory post-hoc analyses. After a median follow-up of 65.4 months, PFS is significantly superior for Ven-Obi compared to Clb-Obi (Hazard ratio [HR] 0.35 [95% CI 0.26-0.46], p < 0.0001). At 5 years after randomization, the estimated PFS rate is 62.6% after Ven-Obi and 27.0% after Clb-Obi. In both arms, MRD status at the end of therapy is associated with longer PFS. MRD + ( ≥ 10-4) status is associated with increased expression of multi-drug resistance gene ABCB1 (MDR1), whereas MRD6 (< 10-6) is associated with BCL2L11 (BIM) expression. Inflammatory response pathways are enriched in MRD+ patient solely in the Ven-Obi arm. These data indicate sustained long-term efficacy of fixed-duration Ven-Obi in patients with previously untreated CLL. The distinct transcriptomic profile of MRD+ status suggests possible biological vulnerabilities.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
- Cancer Institute, University College London, London, UK.
- Francis Crick Institute, London, UK.
| | - Can Zhang
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | | | - Sandra Robrecht
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Yoonha Choi
- Genentech Inc., South San Francisco, CA, USA
| | | | - Alex Kotak
- Roche Products Ltd, Welwyn Garden City, UK
| | | | - Anna Maria Fink
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Eugen Tausch
- Department III of Internal Medicine, Ulm University, Ulm, Germany
| | | | - Matthias Ritgen
- Department II of Internal Medicine, University of Schleswig Holstein, Kiel, Germany
| | - Karl-Anton Kreuzer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | | | | | - Christian P Pallasch
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Lukas P Frenzel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | - Martin Peifer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Translational Genomics, Cologne, Germany
| | - Barbara Eichhorst
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
| | | | | | - Michael Hallek
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Kirsten Fischer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
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52
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Kim MS, Prasad V. Front-line chronic lymphocytic leukemia: The role of chemoimmunotherapy. Am J Hematol 2023; 98:560-561. [PMID: 36701133 DOI: 10.1002/ajh.26864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Affiliation(s)
- Myung Sun Kim
- Medical Oncology/Hematology, Compass Oncology, Portland, Oregon, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Abstract
IMPORTANCE Chronic lymphocytic leukemia (CLL), defined by a minimum of 5 × 109/L monoclonal B cells in the blood, affects more than 200 000 people and is associated with approximately 4410 deaths in the US annually. CLL is associated with an immunocompromised state and an increased rate of complications from infections. OBSERVATIONS At the time of diagnosis, the median age of patients with CLL is 70 years, and an estimated 95% of patients have at least 1 medical comorbidity. Approximately 70% to 80% of patients with CLL are asymptomatic at the time of diagnosis, and one-third will never require treatment for CLL. Prognostic models have been developed to estimate the time to first treatment and the overall survival, but for patients who are asymptomatic, irrespective of disease risk category, clinical observation is the standard of care. Patients with symptomatic disease who have bulky or progressive lymphadenopathy or hepatosplenomegaly and those with a low neutrophil count, anemia, or thrombocytopenia and/or symptoms of fever, drenching night sweats, and weight loss (B symptoms) should be offered treatment. For these patients, first-line treatment consists of a regimen containing either a covalent Bruton tyrosine kinase (BTK) inhibitor (acalabrutinib, zanubrutinib, or ibrutinib) or a B-cell leukemia/lymphoma 2 (BCL2) inhibitor (venetoclax). There is no evidence that starting either class before the other improves outcomes. The covalent BTK inhibitors are typically used indefinitely. Survival rates are approximately 88% at 4 years for acalabrutinib, 94% at 2 years for zanubrutinib, and 78% at 7 years for ibrutinib. Venetoclax is prescribed in combination with obinutuzumab, a monoclonal anti-CD20 antibody, in first-line treatment for 1 year (overall survival, 82% at 5-year follow-up). A noncovalent BTK inhibitor, pitobrutinib, has shown an overall response rate of more than 70% after failure of covalent BTK inhibitors and venetoclax. Phosphoinositide 3'-kinase (PI3K) inhibitors (idelalisib and duvelisib) can be prescribed for disease that progresses with BTK inhibitors and venetoclax, but patients require close monitoring for adverse events such as autoimmune conditions and infections. In patients with multiple relapses, chimeric antigen receptor T-cell (CAR-T) therapy with lisocabtagene maraleucel was associated with a 45% complete response rate. The only potential cure for CLL is allogeneic hematopoietic cell transplant, which remains an option after use of targeted agents. CONCLUSIONS AND RELEVANCE More than 200 000 people in the US are living with a CLL diagnosis, and CLL causes approximately 4410 deaths each year in the US. Approximately two-thirds of patients eventually need treatment. Highly effective novel targeted agents include BTK inhibitors such as acalabrutinib, zanubrutinib, ibrutinib, and pirtobrutinib or BCL2 inhibitors such as venetoclax.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Medical Oncology Division, University of Washington, Seattle
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54
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Frustaci AM, Deodato M, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. Next Generation BTK Inhibitors in CLL: Evolving Challenges and New Opportunities. Cancers (Basel) 2023; 15:1504. [PMID: 36900295 PMCID: PMC10000925 DOI: 10.3390/cancers15051504] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/05/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023] Open
Abstract
Ibrutinib revolutionized the CLL treatment approach and prognosis demonstrating its efficacy and safety even at extended follow-up. During the last few years, several next-generation inhibitors have been developed to overcome the occurrence of toxicity or resistance in patients on continuous treatment. In a head-to-head comparison of two phase III trials, both acalabrutinib and zanubrutinib demonstrated a lower incidence of adverse events in respect to ibrutinib. Nevertheless, resistance mutations remain a concern with continuous therapy and were demonstrated with both first- and next-generation covalent inhibitors. Reversible inhibitors showed efficacy independently of previous treatment and the presence of BTK mutations. Other strategies are currently under development in CLL, especially for high-risk patients, and include BTK inhibitor combinations with BCl2 inhibitors with or without anti-CD20 monoclonal antibodies. Finally, new mechanisms for BTK inhibition are under investigations in patients progressing with both covalent and non-covalent BTK and BCl2 inhibitors. Here we summarize and discuss results from main experiences on irreversible and reversable BTK inhibitors in CLL.
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Affiliation(s)
- Anna Maria Frustaci
- ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
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Edelmann J, Malcikova J, Riches JC. Opinion: What defines high-risk CLL in the post-chemoimmunotherapy era? Front Oncol 2023; 13:1106579. [PMID: 36845738 PMCID: PMC9948015 DOI: 10.3389/fonc.2023.1106579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Affiliation(s)
| | - Jitka Malcikova
- Department of Internal Medicine – Hematology and Oncology, University Hospital Brno, Masaryk University, Brno, Czechia
- Center of Molecular Medicine, Central European Institute of Technology, Masaryk University, Brno, Czechia
| | - John C. Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
- Department of Haemato-Oncology, Barts Health NHS Trust, St. Bartholomew’s Hospital, London, United Kingdom
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56
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Karr M, Roeker L. A History of Targeted Therapy Development and Progress in Novel-Novel Combinations for Chronic Lymphocytic Leukemia (CLL). Cancers (Basel) 2023; 15:1018. [PMID: 36831364 PMCID: PMC9954076 DOI: 10.3390/cancers15041018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
Over the last 10 years, the traditional treatment paradigms for CLL have been upended as the use of traditional chemoimmunotherapy regimens has declined in favor of novel targeted therapies. Targeted therapies have become the new standard of care in CLL given their superior progression-free survival (and overall survival, in some cases) when compared with chemoimmunotherapy, as well as their improved toxicity profiles. Targeted agents are FDA approved for the treatment of CLL including ibrutinib, acalabrutinib, zanubrutinib, and venetoclax. Importantly, as opposed to traditional chemotherapy regimens, the benefits of these targeted therapies appear to be consistent regardless of high-risk mutational status. In this review, we discuss the pivotal CLL studies of the last decade and the data supporting doublet and triplet novel-novel combinations. We explore the use of new surrogate end points for PFS/OS in targeted therapies such as undetectable minimal residual disease (uMRD) and their potential role in minimizing toxicity by permitting earlier treatment discontinuation. We also highlight areas that warrant further exploration and future studies that may help address some of these key questions.
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Affiliation(s)
- Matthew Karr
- Heme-BMT Hospitalist Division, University of California, San Francisco, CA 94720, USA
| | - Lindsey Roeker
- Memorial Sloan Kettering Cancer Center, Division of Hematology/Oncology, New York, NY 10065, USA
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57
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Ryan CE, Brander DM, Barr PM, Tyekucheva S, Hackett LR, Collins MC, Fernandes SM, Ren Y, Zhou Y, McDonough MM, Walker HA, McEwan MR, Abramson JS, Jacobsen ED, LaCasce AS, Fisher DC, Brown JR, Davids MS. A phase 1b study of ibrutinib in combination with obinutuzumab in patients with relapsed or refractory chronic lymphocytic leukemia. Leukemia 2023; 37:835-842. [PMID: 36717653 DOI: 10.1038/s41375-023-01830-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
This study investigated ibrutinib plus obinutuzumab in relapsed/refractory CLL, evaluating tolerability of 3 sequencing regimens as well as overall safety and efficacy. Fifty-two patients were initially randomized 1:1:1 to receive either obinutuzumab 1 month before ibrutinib initiation, ibrutinib 1 month prior to obinutuzumab initiation, or to start both drugs concomitantly. Higher rates of infusion-related reactions were observed with the first sequence, and only the latter 2 cohorts were expanded. Grade 4 hematologic toxicity was uncommon, and notable all-grade non-hematologic toxicities included bruising (58%), hypertension (46%), arthralgia (38%), diarrhea (37%), transaminitis (35%), atrial fibrillation (21%), and serious infection (17%). Best overall response rate was 96% (including 40% CR and 56% PR). Best rates of undetectable minimal residual disease in peripheral blood and bone marrow were 27% and 19%, respectively. With a median follow-up of 41.5 months, four-year progression-free and overall survival rates are 74% and 93%, respectively. Correlative studies demonstrated that serum CCL4 and CXCL13 levels were associated with clinical response, and BH3 profiling revealed increased BCL-2 and BCL-xL dependence in CLL cells from patients on treatment. Overall, ibrutinib plus obinutuzumab was highly active, with a manageable safety profile, supporting further investigation of this type of approach in relapsed/refractory CLL.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Durham, NC, USA
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Liam R Hackett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary C Collins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stacey M Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mikaela M McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heather A Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Monica R McEwan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital, Boston, MA, USA
| | - Eric D Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann S LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Wang Z, Zhou H, Xu J, Wang J, Niu T. Safety and efficacy of dual PI3K-δ, γ inhibitor, duvelisib in patients with relapsed or refractory lymphoid neoplasms: A systematic review and meta-analysis of prospective clinical trials. Front Immunol 2023; 13:1070660. [PMID: 36685572 PMCID: PMC9845779 DOI: 10.3389/fimmu.2022.1070660] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/07/2022] [Indexed: 01/06/2023] Open
Abstract
Background Duvelisib is the first FDA-approved oral dual inhibitor of phosphatidylinositol-3-kinase PI3K-delta (PI3K-δ) and PI3K-gamma (PI3K-γ). Although many clinical studies support the efficacy of duvelisib, the safety of duvelisib remains with great attention. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of duvelisib in treating different relapsed or refractory (RR) lymphoid neoplasm types. Methods We searched prospective clinical trials from PUBMED, EMBASE, Cochrane Library, and ClinicalTrials.gov. For efficacy analysis, Overall response rate (ORR), complete response rate (CR), partial response rate (PR), rate of stable disease (SDR), rate of progressive disease (PDR), median progression-free survival (mPFS), 12-/24-month PFS, and 12-month overall survival (OS) were assessed. For safety analysis, the incidences of any grade and grade ≥3 adverse events (AEs), serious AEs, and treatment-related discontinuation and death were evaluated. Subgroup analysis based on the disease type was performed. Results We included 11 studies and 683 patients, including 305 chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), 187 B-cell indolent non-Hodgkin lymphoma (iNHL), 39 B-cell aggressive non-Hodgkin lymphoma (aNHL), and 152 T-cell non-Hodgkin lymphoma (T-NHL) patients. The pooled ORR in CLL/SLL, iNHL, aNHL and T-NHL was 70%, 70%, 28% and 47%, respectively. Additionally, the pooled ORR in CLL/SLL patients with or without TP53 mutation/17p-deletion (62% vs. 74%, p=0.45) and in follicular lymphoma (FL) or other iNHL (69% vs. 57%, p=0.38) had no significant differences. Mantle cell lymphoma (MCL) patients had higher pooled ORR than other aNHL (68% vs. 17%, p=0.04). Angioimmunoblastic TCL (AITL) patients had higher pooled ORR than other PTCL patients (67% vs. 42%, p=0.01). The pooled incidence of any grade, grade ≥3, serious AEs, treatment-related discontinuation and death was 99%, 79%, 63%, 33% and 3%, respectively. The most frequent any-grade AEs were diarrhea (47%), ALT/AST increase (39%), and neutropenia (38%). The most frequent grade ≥3 AEs were neutropenia (25%), ALT/AST increased (16%), diarrhea (12%), and anemia (12%). Conclusion Generally, duvelisib could offer favorable efficacy in patients with RR CLL/SLL, iNHL, MCL, and AITL. Risk and severity in duvelisib treatment may be mitigated through proper identification and management.
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59
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Ahn IE, Brown JR. Selecting initial therapy in CLL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:323-328. [PMID: 36485152 PMCID: PMC9820765 DOI: 10.1182/hematology.2022000343] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Targeted therapy is a powerful treatment option in chronic lymphocytic leukemia (CLL) that has outperformed conventional chemoimmunotherapy in most clinical settings. Except for selected young, fit patients with a mutated immunoglobulin heavy chain variable region gene, most patients benefit from targeted therapy with either a continuous BTK inhibitor or 1-year fixed-duration venetoclax-obinutuzumab as first-line treatment of CLL. Treatment selection is driven by patient-, treatment-, and disease-related factors, encompassing patient preference, concomitant medications, comorbidities, safety profile of the regimen, and TP53 aberration. Clinical trials are actively investigating the simultaneous inhibition of Bruton's tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL-2) proteins with or without a CD20 monoclonal antibody, which can achieve deep response in most patients (52%-89% undetectable minimal residual disease in bone marrow).
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60
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Visentin A, Mauro FR, Catania G, Fresa A, Vitale C, Sanna A, Mattiello V, Cibien F, Sportoletti P, Gentile M, Rigolin GM, Quaglia FM, Murru R, Gozzetti A, Molica S, Marchetti M, Pravato S, Angotzi F, Cellini A, Scarfò L, Reda G, Coscia M, Laurenti L, Ghia P, Foà R, Cuneo A, Trentin L. Obinutuzumab plus chlorambucil versus ibrutinib in previously untreated chronic lymphocytic leukemia patients without TP53 disruptions: A real-life CLL campus study. Front Oncol 2022; 12:1033413. [PMID: 36479077 PMCID: PMC9719965 DOI: 10.3389/fonc.2022.1033413] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/20/2022] [Indexed: 08/13/2023] Open
Abstract
One of the main issues in the treatment of patients with chronic lymphocytic leukemia (CLL) deals with the choice between continuous or fixed-duration therapy. Continuous ibrutinib (IB), the first-in-class BTK inhibitor, and obinutuzumab-chlorambucil (G-CHL) are commonly used therapies for elderly and/or comorbid patients. No head-to-head comparison has been carried out. Within the Italian campus CLL network, we performed a retrospective study on CLL patients without TP53 disruption treated with IB or G-CHL as first-line therapy. Patients in the G-CHL arm had a higher CIRS score and the worst renal function. The overall response rates between the G-CHL and IB arms were similar, but more complete remissions (CRs) were achieved with G-CHL (p = 0.0029). After a median follow-up of 30 months, the progression-free survival (PFS, p = 0.0061) and time to next treatment (TTNT, p = 0.0043), but not overall survival (OS, p = 0.6642), were better with IB than with G-CHL. Similar results were found after propensity score matching and multivariate analysis. While PFS and TTNT were longer with IB than with G-CHL in IGHV unmutated patients (p = 0.0190 and 0.0137), they were superimposable for IGHV mutated patients (p = 0.1900 and 0.1380). In the G-CHL arm, the depth of response (79% vs. 68% vs. 38% for CR, PR and SD/PD; p < 0.0001) and measurable residual disease (MRD) influenced PFS (78% vs. 53% for undetectable MRD vs. detectable MRD, p = 0.0203). Hematological toxicities were common in the G-CHL arm, while IB was associated with higher costs. Although continuous IB provides better disease control in CLL, IGHV mutated patients and those achieving an undetectable MRD show a marked clinical and economic benefit from a fixed-duration obinutuzumab-based treatment.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, Rome, Italy
| | - Gioachino Catania
- Division of Hematology, Hospital Saints (A. O. SS) Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Alberto Fresa
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Candida Vitale
- Department of Molecular Biotechnology and health Sciences, University of Torino and Division of Hematology, University Hospital (A.O.U.) Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Veronica Mattiello
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | | | - Paolo Sportoletti
- Hematology and Clinical Immunology Unit, University of Perugia, Perugia, Italy
| | | | - Gian Matteo Rigolin
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Francesca Maria Quaglia
- Department of Medicine, Section of Hematology, University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco ARNAS “G. Brotzu”, Cagliari, Italy
| | | | - Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Monia Marchetti
- Division of Hematology, Hospital Saints (A. O. SS) Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Francesco Angotzi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Alessandro Cellini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Lydia Scarfò
- Strategic Program on CLL, University Health and Science “San Raffaele”, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | - Marta Coscia
- Department of Molecular Biotechnology and health Sciences, University of Torino and Division of Hematology, University Hospital (A.O.U.) Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Laurenti
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Paolo Ghia
- Strategic Program on CLL, University Health and Science “San Raffaele”, Milan, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
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Kutsch N, Fink AM, Fischer K. Management of front line chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S3-S10. [PMID: 36125035 DOI: 10.1002/ajh.26677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 08/01/2022] [Indexed: 11/11/2022]
Abstract
Treatment options with targeted agents have changed the treatment landscape of CLL profoundly. Besides chemoimmunotherapy, treatment regimen approved for frontline therapy include continuous treatment with BTK inhibitors like ibrutinib and acalabrutinib or fixed-duration regimen like venetoclax-obinutuzumab with the approval of venetoclax-ibrutinib to be awaited. Although these agents have usually manageable side effects, toxicities might limit choices for the individual patient. We here discuss latest trial data and propose a treatment algorithm for frontline treatment of CLL according to fitness and relevant genetic risk factors like IGHV mutational status and TP53 aberrations.
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Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
| | - Anna Maria Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
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62
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Should Patients with Waldenström Macroglobulinemia Receive a BTK Inhibitor as Frontline Therapy? HEMATO 2022. [DOI: 10.3390/hemato3040046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Waldenström Macroglobulinemia (WM) is a rare indolent lymphoma with heterogeneous clinical presentation. As there are no randomised trials suggesting the best treatment option in treatment-naive patients, guidelines suggest either rituximab-combining regimens or BTK-inhibitors (BTKi) as feasible alternatives. Several factors play in the decision-making process: patients’ age and fitness, disease characteristics and genotype. Chemoimmunotherapy (CIT) represents a fixed-duration, less expensive and effective option, able to achieve prolonged time-to-next treatment even in patients with unfavourable genotypes. Immunosuppression and treatment-related second cancers may represent serious concerns. Proteasome-inhibitor-based regimens are effective with rapid disease control, although bortezomib-related neuropathy discourages the choice of these agents and treatment schedules may not be easily manageable in the elderly. BTKi have demonstrated high rates of response and prolonged survival together with the convenience of an oral administration and limited cytopenias. However, outcomes are impacted by genotype and some concerns remain, in particular the continuous drug exposure that may result in extra-haematological complications and drug resistance. Although next-generation BTKi have improved treatment tolerance, the question whether BTKi should be offered as frontline therapy to every patient is still debated. Giving fixed-duration schedule, prolonged time-to-next treatment and outcomes independent of genotype, CIT is still our preferred choice in WM. However, BTKi remain a valuable option in frail patients unsuitable for CIT.
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Ryan CE, Davids MS, Hermann R, Shahkarami M, Biondo J, Abhyankar S, Alhasani H, Sharman JP, Mato AR, Roeker LE. MAJIC: a phase III trial of acalabrutinib + venetoclax versus venetoclax + obinutuzumab in previously untreated chronic lymphocytic leukemia or small lymphocytic lymphoma. Future Oncol 2022; 18:3689-3699. [PMID: 36102212 DOI: 10.2217/fon-2022-0456] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Here we describe the rationale and design of MAJIC, a phase III, prospective, multicenter, randomized trial comparing the combination of the BTK inhibitor acalabrutinib plus the BCL2 inhibitor venetoclax versus the combination of venetoclax plus obinutuzumab as frontline treatment for chronic lymphocytic leukemia or small lymphocytic lymphoma. In both treatment arms, disease response (assessed by International Workshop on Chronic Lymphocytic Leukemia criteria) and minimal residual disease will be used to guide therapy duration, with all patients ultimately discontinuing treatment after a maximum of 2 years. The primary end point is progression-free survival. Key secondary end points include rates of undetectable minimal residual disease, overall response and overall survival. This study will address key unanswered questions in frontline chronic lymphocytic leukemia/small lymphocytic lymphoma therapy by investigating the optimal duration of finite treatment and identifying the optimal venetoclax doublet regimen.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | | | | | - Jeff P Sharman
- Willamette Valley Cancer Institute & Research Center/US Oncology, Eugene, OR, USA
| | - Anthony R Mato
- CLL Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lindsey E Roeker
- CLL Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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64
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Panjideh H, Niesler N, Weng A, Fuchs H. Improved Therapy of B-Cell Non-Hodgkin Lymphoma by Obinutuzumab-Dianthin Conjugates in Combination with the Endosomal Escape Enhancer SO1861. Toxins (Basel) 2022; 14:toxins14070478. [PMID: 35878216 PMCID: PMC9318199 DOI: 10.3390/toxins14070478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 12/28/2022] Open
Abstract
Immunotoxins do not only bind to cancer-specific receptors to mediate the elimination of tumor cells through the innate immune system, but also increase target cytotoxicity by the intrinsic toxin activity. The plant glycoside SO1861 was previously reported to enhance the endolysosomal escape of antibody-toxin conjugates in non-hematopoietic cells, thus increasing their cytotoxicity manifold. Here we tested this technology for the first time in a lymphoma in vivo model. First, the therapeutic CD20 antibody obinutuzumab was chemically conjugated to the ribosome-inactivating protein dianthin. The cytotoxicity of obinutuzumab-dianthin (ObiDi) was evaluated on human B-lymphocyte Burkitt’s lymphoma Raji cells and compared to human T-cell leukemia off-target Jurkat cells. When tested in combination with SO1861, the cytotoxicity for target cells was 131-fold greater than for off-target cells. In vivo imaging in a xenograft model of B-cell lymphoma in mice revealed that ObiDi/SO1861 efficiently prevents tumor growth (51.4% response rate) compared to the monotherapy with ObiDi (25.9%) and non-conjugated obinutuzumab (20.7%). The reduction of tumor volume and overall survival was also improved. Taken together, our results substantially contribute to the development of a combination therapy with SO1861 as a platform technology to enhance the efficacy of therapeutic antibody-toxin conjugates in lymphoma and leukemia.
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Affiliation(s)
- Hossein Panjideh
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Augustenburger Platz 1, D-13353 Berlin, Germany; (H.P.); (N.N.)
| | - Nicole Niesler
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Augustenburger Platz 1, D-13353 Berlin, Germany; (H.P.); (N.N.)
| | - Alexander Weng
- Institut für Pharmazie, Freie Universität Berlin, Königin-Luise-Straße 2+4, D-14195 Berlin, Germany;
| | - Hendrik Fuchs
- Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Diagnostic Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Augustenburger Platz 1, D-13353 Berlin, Germany; (H.P.); (N.N.)
- Correspondence:
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Wierda WG. Ibrutinib Plus Venetoclax for First-Line Chronic Lymphocytic Leukemia Treatment. NEJM EVIDENCE 2022; 1:EVIDe2200093. [PMID: 38319264 DOI: 10.1056/evide2200093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Ibrutinib Plus Venetoclax for First-Line Chronic Lymphocytic Leukemia TreatmentSmall-molecule inhibitor targeted therapy for patients with chronic lymphocytic leukemia (CLL) began with ibrutinib, the oral covalent inhibitor of Bruton's tyrosine kinase (BTKi). Phase III clinical trials demonstrated improved progression-free survival with ibrutinib compared with current standard treatment for first-line1-4 and relapsed or refractory CLL.5 BTKi therapy is extremely effective at eliminating nodal disease and prevents progression, including for patients with high-risk del(17p)/mutated-TP53 CLL. Patients receive BTKi maintenance until progression or side effects become limiting.
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Affiliation(s)
- William G Wierda
- Division of Cancer Medicine, Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston
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Marchetti M, Vitale C, Rigolin GM, Vasile A, Visentin A, Scarfò L, Coscia M, Cuneo A. Old and New Drugs for Chronic Lymphocytic Leukemia: Lights and Shadows of Real-World Evidence. J Clin Med 2022; 11:jcm11082076. [PMID: 35456167 PMCID: PMC9028394 DOI: 10.3390/jcm11082076] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/16/2022] Open
Abstract
Several novel treatments for chronic lymphocytic leukemia (CLL) have been recently approved based on the results of randomized clinical trials. However, real-world evidence (RWE) is also requested before and after drug authorization in order to confirm safety and to provide data for health technology assessments. We conducted a scoping review of the available RWE for targeted treatments of CLL, namely ibrutinib, acalabrutinib, idelalisib, and venetoclax, as well as for chemoimmunotherapy (CIT). In particular, we searched studies published since 1 January 2010 and reported outcomes of the above treatments based on health databases, registries, or phase IV studies, including named-patient programs. We included both full papers and abstracts of studies presented at major meetings. Overall, 110 studies were selected and analyzed: 28,880 patients were treated with ibrutinib, 1424 with idelalisib, 751 with venetoclax, 496 with acalabrutinib, and 14,896 with CIT. Reported discontinuation rates were higher than in clinical trials, while effectiveness could not be indirectly compared with clinical trials since a detailed case mix, including cytogenetic risk factors, was partially available and propensity scores rarely applied. RWE on CLL can help to set realistic outcomes with novel treatments, however, real-world studies should be fostered, and available data shared.
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Affiliation(s)
- Monia Marchetti
- Haematology and Transplant Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Correspondence:
| | - Candida Vitale
- Hematology Unit, Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (C.V.); (M.C.)
| | - Gian Matteo Rigolin
- Haematology Unit, Azienda Ospedaliera Universitaria di Ferrara, 44121 Ferrara, Italy; (G.M.R.); (A.C.)
- Haematology and Rheumatology Section, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Alessandra Vasile
- Department of Public Health, University of Eastern Pedemont, 28100 Novara, Italy;
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, 35128 Padua, Italy;
| | - Lydia Scarfò
- Division of Experimental Oncology, Department of Onco-Hematology, IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Marta Coscia
- Hematology Unit, Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (C.V.); (M.C.)
| | - Antonio Cuneo
- Haematology Unit, Azienda Ospedaliera Universitaria di Ferrara, 44121 Ferrara, Italy; (G.M.R.); (A.C.)
- Haematology and Rheumatology Section, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
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Robak T, Witkowska M, Smolewski P. The Role of Bruton's Kinase Inhibitors in Chronic Lymphocytic Leukemia: Current Status and Future Directions. Cancers (Basel) 2022; 14:771. [PMID: 35159041 PMCID: PMC8833747 DOI: 10.3390/cancers14030771] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 12/20/2022] Open
Abstract
The use of Bruton's tyrosine kinase (BTK) inhibitors has changed the management and clinical history of patients with chronic lymphocytic leukemia (CLL). BTK is a critical molecule that interconnects B-cell antigen receptor (BCR) signaling. BTKis are classified into two categories: irreversible (covalent) inhibitors and reversible (non-covalent) inhibitors. Ibrutinib was the first irreversible BTK inhibitor approved by the U.S. Food and Drug Administration in 2013 as a breakthrough therapy in CLL patients. Subsequently, several studies have evaluated the efficacy and safety of new agents with reduced toxicity when compared with ibrutinib. Two other irreversible, second-generation BTK inhibitors, acalabrutinib and zanubrutinib, were developed to reduce ibrutinib-mediated adverse effects. Additionally, new reversible BTK inhibitors are currently under development in early-phase studies to improve their activity and to diminish adverse effects. This review summarizes the pharmacology, clinical efficacy, safety, dosing, and drug-drug interactions associated with the treatment of CLL with BTK inhibitors and examines their further implications.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
| | - Magda Witkowska
- Department of Experimental Hematology, Medical University of Lodz, 93-510 Lodz, Poland; (M.W.); (P.S.)
| | - Piotr Smolewski
- Department of Experimental Hematology, Medical University of Lodz, 93-510 Lodz, Poland; (M.W.); (P.S.)
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