101
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Robak T. Will combination therapy with targeted drugs be better for achieving remission in chronic lymphocytic leukemia? Expert Opin Pharmacother 2017; 18:1675-1678. [DOI: 10.1080/14656566.2017.1373094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
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102
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Abstract
OPINION STATEMENT The front-line management of patients with chronic lymphocytic leukemia (CLL) has evolved significantly in recent years due to introduction of novel, targeted agents. Upon CLL diagnosis, physicians should determine whether treatment or careful observation is indicated. Once treatment is required, choice of therapy should be based on the age and fitness of the patient and the distinct molecular profile of their disease. As multiple novel agents are in various stages of development, all patients regardless of their age, fitness, and disease risk should be evaluated for clinical trial participation before initiating any front-line therapy. If no clinical trial is available, we provide our recommendations for front-line treatment of CLL patients. Healthy, young patients with low-risk disease (mutated IgVH, del (13q)) should be offered fludarabine, chlorambucil, and rituximab (FCR), while similar patients with high-risk disease (unmutated IgVH, del (17p), del (11q), and complex karyotype) should be considered for ibrutinib therapy. For those young, fit patients with high-risk disease and a contraindication to ibrutinib, FCR, or high-dose methylprednisolone and rituximab are options. In regard to older, unfit patients, a careful assessment of their fitness and ability to tolerate treatment should be undertaken before starting therapy. Those who have poor performance and multiple medical comorbidities should be considered for palliative care alone. However, those who are fit enough for treatment can be offered ibrutinib. If there is a contraindication to ibrutinib, they can be separated into low- and high-risk molecular groups. For the low-risk patients, bendamustine and rituximab or obinutuzumab and chlorambucil can be considered. For the high-risk patients, treatment with rituximab and lenalidomide is an option. Herein, we provide an evidence-based front-line treatment algorithm for CLL patients based upon fitness and molecular risk.
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103
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de Weerdt I, Koopmans SM, Kater AP, van Gelder M. Incidence and management of toxicity associated with ibrutinib and idelalisib: a practical approach. Haematologica 2017; 102:1629-1639. [PMID: 28775119 PMCID: PMC5622847 DOI: 10.3324/haematol.2017.164103] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 07/06/2017] [Indexed: 12/22/2022] Open
Abstract
The use of novel B-cell receptor signaling inhibitors results in high response rates and long progression-free survival in patients with indolent B-cell malignancies, such as chronic lymphocytic leukemia, follicular lymphoma, mantle cell lymphoma and Waldenström macroglobulinemia. Ibrutinib, the first-in-class inhibitor of Bruton tyrosine kinase, and idelalisib, the first-in-class inhibitor of phosphatidylinositol 3-kinase δ, have recently been approved for the treatment of several indolent B-cell malignancies. These drugs are especially being used for previously unmet needs, i.e., for patients with relapsed or refractory disease, high-risk cytogenetic or molecular abnormalities, or with comorbidities. Treatment with ibrutinib and idelalisib is generally well tolerated, even by elderly patients. However, the use of these drugs may come with toxicities that are distinct from the side effects of immunochemotherapy. In this review we discuss the most commonly reported and/or most clinically relevant adverse events associated with these B-cell receptor inhibitors, with special emphasis on recommendations for their management.
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Affiliation(s)
- Iris de Weerdt
- Department of Hematology, Academic Medical Center, Amsterdam, the Netherlands.,Department of Experimental Immunology, Academic Medical Center, Amsterdam, the Netherlands
| | - Suzanne M Koopmans
- Division of Hematology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Arnon P Kater
- Department of Hematology, Academic Medical Center, Amsterdam, the Netherlands .,Lymphoma and Myeloma Center Amsterdam, LYMMCARE, the Netherlands
| | - Michel van Gelder
- Division of Hematology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
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104
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105
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Damlaj M, Al Balwi M, Al Mugairi AM. Ibrutinib therapy is effective in B-cell prolymphocytic leukemia exhibiting MYC aberrations. Leuk Lymphoma 2017; 59:739-742. [DOI: 10.1080/10428194.2017.1347653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Moussab Damlaj
- Division of Hematology & HSCT, Department of Oncology, King Abdul-Aziz Medical City, Riyadh, KSA
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, KSA
| | - Mohammed Al Balwi
- King Abdullah International Medical Research Center, Riyadh, KSA
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, KSA
- Department of Pathology and Laboratory Medicine, King Abdul-Aziz Medical City, Riyadh, KSA
| | - Areej M. Al Mugairi
- Department of Pathology and Laboratory Medicine, King Abdul-Aziz Medical City, Riyadh, KSA
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106
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Tran PN, O'Brien S. The safety of Bruton's tyrosine kinase inhibitors for the treatment of chronic lymphocytic leukemia. Expert Opin Drug Saf 2017. [PMID: 28627951 DOI: 10.1080/14740338.2017.1344213] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The approval of ibrutinib has revolutionized the therapeutic landscape of chronic lymphocytic leukemia (CLL). Currently ibrutinib is indicated for patients that are both treatment naïve as well as those with relapsed CLL. Ibrutinib is generally well-tolerated with durable responses that improve over time in most patients. Important toxicities include atrial fibrillation and bleeding. Areas cover: This review covers the pharmacokinetics, pharmacodynamics, safety and efficacy of ibrutinib in the treatment of CLL. We also compare ibrutinib with other kinase inhibitors and chemoimmunotherapy regimens using data from clinical trials. A literature search utilized the PubMed database. Expert opinion: Despite the efficacy and tolerability of ibrutinib, important questions remain, which include selection of patients receiving ibrutinib in the first and subsequent lines of treatment, optimal dosing, sequential use of ibrutinib versus other kinase inhibitors and combination therapy. Prospective studies should incorporate minimal residual disease (MRD) status as a clinical endpoint to determine whether patients can be taken off kinase inhibitors.
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Affiliation(s)
- Phu N Tran
- a Division of Hematology-Oncology , University of California Irvine , Orange , CA , USA
| | - Susan O'Brien
- a Division of Hematology-Oncology , University of California Irvine , Orange , CA , USA
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107
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Thorp BC, Badoux X. Atrial fibrillation as a complication of ibrutinib therapy: clinical features and challenges of management. Leuk Lymphoma 2017. [PMID: 28629235 DOI: 10.1080/10428194.2017.1339874] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Ibrutinib is a Bruton's tyrosine kinase (BTK) inhibitor finding increasingly widespread use in non-Hodgkin lymphoma. Evidence of an increased risk of atrial fibrillation (AF) emerged in Phase III studies with a median incidence of approximately 6%. The mechanism remains unknown, but inhibition of a cardioprotective pathway has been proposed. Ibrutinib induces a platelet function defect, increasing the bleeding risk of anticoagulation for AF stroke prophylaxis. Multiple potential drug interactions are an added complication. In this review we examine the characteristics and management of the reported cases of AF with ibrutinib and where possible make recommendations. The evidence suggests dose reduction or temporary suspension of drug, are feasible alternative to discontinuation. The optimum choice of thromboprophylaxis has not been determined, but we propose the use of novel anticoagulants (NOACs) and avoidance of anti-platelet agents where possible. Further research and consensus guidelines are required.
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Affiliation(s)
- Bronwyn C Thorp
- a Department of Haematology , St George Hospital , Sydney , NSW , Australia
| | - Xavier Badoux
- a Department of Haematology , St George Hospital , Sydney , NSW , Australia
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108
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Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL. Leukemia 2017; 32:83-91. [PMID: 28592889 PMCID: PMC5770586 DOI: 10.1038/leu.2017.175] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 12/14/2022]
Abstract
In the phase 3 RESONATE study, ibrutinib demonstrated superior progression-free survival (PFS), overall survival (OS) and overall response rate (ORR) compared with ofatumumab in relapsed/refractory CLL patients with high-risk prognostic factors. We report updated results from RESONATE in these traditionally chemotherapy resistant high-risk genomic subgroups at a median follow-up of 19 months. Mutations were detected by Foundation One Heme Panel. Baseline mutations in the ibrutinib arm included TP53 (51%), SF3B1 (31%), NOTCH1 (28%), ATM (19%) and BIRC3 (14%). Median PFS was not reached, with 74% of patients randomized to ibrutinib alive and progression-free at 24 months. The improved efficacy of ibrutinib vs ofatumumab continues in all prognostic subgroups including del17p and del11q. No significant difference within the ibrutinib arm was observed for PFS across most genomic subtypes, although a subset carrying both TP53 mutation and del17p had reduced PFS compared with patients with neither abnormality. Reduced PFS or OS was not evident in patients with only del17p. PFS was significantly better for ibrutinib-treated patients in second-line vs later lines of therapy. The robust clinical activity of ibrutinib continues to show ongoing efficacy and acceptable safety consistent with prior reports, independent of various known high-risk mutations.
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109
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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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110
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Kubuschok B, Trepel M. Learning from the failures of drug discovery in B-cell non-Hodgkin lymphomas and perspectives for the future: chronic lymphocytic leukemia and diffuse large B-cell lymphoma as two ends of a spectrum in drug development. Expert Opin Drug Discov 2017; 12:733-745. [PMID: 28494631 DOI: 10.1080/17460441.2017.1329293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Despite substantial recent advances, there is still an unmet need for better therapies in B-cell non Hodgkin lymphomas (B-NHL), especially in relapsed or refractory disease. Many novel targeted drugs have been developed based on a better molecular understanding of B-NHL. Areas covered: This article focuses on chronic lymphocytic leukemia (CLL) as a representative for indolent lymphomas and paradigmatic for the tremendous progress in treating B-NHL on the one hand and diffuse large B-cell lymphoma (DLBCL) as a representative for aggressive lymphomas and paradigmatic for many unsolved problems in lymphoma treatment or the other hand. We highlight salient points in current therapies targeting genetic, epigenetic, immunological and microenvironmental alterations. Possible reasons for drug failure in clinical trials like tumor heterogeneity, clonal evolution and drug resistance mechanisms are discussed. Based thereon, some perspectives for further drug discovery are given. Expert opinion: In view of the pathogenetic complexity of lymphomas, therapies targeting exclusively a single alteration may fail because resistance mechanisms are present either initially or evolve during treatment. Therefore, future therapies in B-NHL may have to target the greatest possible number of genetic, immunological or epigenetic alterations still allowing tolerability and to monitor these alterations during therapy.
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Affiliation(s)
- Boris Kubuschok
- a Department of Internal Medicine II , Klinikum Augsburg , Augsburg , Germany.,b Department of Hematology and Oncology , University of Saarland Medical School , Homburg , Germany
| | - Martin Trepel
- a Department of Internal Medicine II , Klinikum Augsburg , Augsburg , Germany.,c Department of Oncology and Hematology , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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111
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García-Marco JA, Delgado J, Hernández-Rivas JA, Ramírez Payer Á, Loscertales Pueyo J, Jarque I, Abrisqueta P, Giraldo P, Martínez R, Yáñez L, Terol MJ, González M, Bosch F. Update of the Grupo Español de Leucemia Linfocítica Crónica clinical guidelines of the management of chronic lymphocytic leukemia. Med Clin (Barc) 2017; 148:381.e1-381.e9. [PMID: 28236475 DOI: 10.1016/j.medcli.2016.12.030] [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] [Received: 09/28/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE The broad therapeutic arsenal and the biological heterogeneity of patients with chronic lymphocytic leukemia (CLL) makes it difficult to standardize treatment for CLL patients with specific clinical settings in routine clinical practice. These considerations prompted us to elaborate the present consensus document, which constitutes an update of the previous version published in 2013, mainly focusing on novel treatment strategies that have been developed over last 5 years, namely B-cell receptor inhibitors (ibrutinib and idelalisib), anti-CD20 monoclonal antibodies (ofatumumab and obinutuzumab), and Bcl-2 inhibitors (venetoclax). MATERIAL AND METHODS A group of experts from the Spanish Chronic Lymphocytic Leukemia Group reviewed all published literature from January 2010 to January 2016, in order to provide recommendations based on clinical evidence. For those areas without strong scientific evidence, the panel of experts established consensus criteria based on their clinical experience. RESULTS The project has resulted in several practical recommendations that will facilitate the diagnosis, treatment, and follow-up of patients with CLL. CONCLUSIONS There are many controversial issues in the management of CLL with no appropriate studies for making consensus recommendations.
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Affiliation(s)
- José A García-Marco
- Servicio de Hematología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España.
| | - Julio Delgado
- Servicio de Hematología, Hospital Clínic i Provincial, Barcelona, España
| | | | - Ángel Ramírez Payer
- Servicio de Hematología, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | | | - Isidro Jarque
- Servicio de Hematología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Pau Abrisqueta
- Servicio de Hematología, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Pilar Giraldo
- Servicio de Hematología, Hospital Universitario Miguel Servet, Zaragoza, España
| | - Rafael Martínez
- Servicio de Hematología, Hospital Clínico Universitario San Carlos, Madrid, España
| | - Lucrecia Yáñez
- Servicio de Hematología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Mª José Terol
- Servicio de Hematología, Hospital Clínico Universitario, Valencia, España
| | - Marcos González
- Servicio de Hematología, Hospital Clínico Universitario-Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
| | - Francesc Bosch
- Servicio de Hematología, Hospital Universitario Vall d'Hebron, Barcelona, España
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112
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Abstract
Ibrutinib (Imbruvica®) is an oral irreversible inhibitor of Bruton's tyrosine kinase, a B-cell receptor (BCR) signalling kinase expressed by various haematopoietic cells, B-cell lymphomas and leukaemias. The drug is indicated for the treatment of certain haematological malignancies, including chronic lymphocytic leukaemia (CLL)/small lymphocytic lymphoma (SLL), which are the focus of this review. In phase III CLL/SLL trials, ibrutinib monotherapy was more effective than chlorambucil in the first-line treatment of elderly patients (RESONATE-2) and more effective than ofatumumab in previously-treated adults (RESONATE). Likewise, a combination of ibrutinib, bendamustine and rituximab was more effective in previously-treated adults than bendamustine plus rituximab in a phase III placebo-controlled study (HELIOS). These ibrutinib regimens were associated with significantly better progression-free survival, overall response rates, and overall survival than the comparators (in protocol-specified or planned analyses), with ibrutinib therapy providing benefit regardless of adverse prognostic factors, such as del(17p)/TP53 mutation and del(11q). Ibrutinib has an acceptable tolerability profile, although certain adverse events (e.g. bleeding and atrial fibrillation) require consideration. Redistribution lymphocytosis can occur, but is not indicative of disease progression. Although longer-term data would be beneficial, ibrutinib is a welcome treatment option for patients with CLL, including those who have higher-risk disease or are less physically fit. Indeed, current EU and US guidelines recommend/prefer the drug for the first- and/or subsequent-line treatment of certain patients, including those with del(17p)/TP53 mutation.
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Affiliation(s)
- Emma D Deeks
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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113
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Long-term follow-up of patients with CLL treated with the selective Bruton's tyrosine kinase inhibitor ONO/GS-4059. Blood 2017; 129:2808-2810. [PMID: 28377400 DOI: 10.1182/blood-2017-02-765115] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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114
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Abstract
Personalization of therapy to target specific molecular pathways has been placed in the forefront of cancer research. Initial reports from clinical trials designed to select patients for appropriate treatment on the basis of tumor characteristics not only have generated considerable excitement but also have identified several challenges. These challenges include the overcoming of regulatory and logistic difficulties, identification of the best selection biomarkers and diagnostic platforms that can be applied in the clinical setting, definition of relevant outcomes in small preselected patient populations, and the design of methods that facilitate rapid enrollment and interpretation of clinical trials by aggregating data across histologically diverse malignancies with common genetic alterations. Furthermore, because our knowledge of the functional consequences of many genetic alterations lags, investigators and sponsors struggle with choosing between ideal clinical trial designs and more practical ones. These challenges are amplified when more than one biomarker is used to select patients for a combination of targeted agents. This review summarizes the current status and challenges of clinical trials in the genomic era and proposes ways to address these challenges.
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Affiliation(s)
- Erel Joffe
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexia Iasonos
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anas Younes
- All authors: Memorial Sloan Kettering Cancer Center, New York, NY
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115
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Circulating tumour DNA reflects treatment response and clonal evolution in chronic lymphocytic leukaemia. Nat Commun 2017; 8:14756. [PMID: 28303898 PMCID: PMC5357854 DOI: 10.1038/ncomms14756] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/30/2017] [Indexed: 12/15/2022] Open
Abstract
Several novel therapeutics are poised to change the natural history of chronic lymphocytic leukaemia (CLL) and the increasing use of these therapies has highlighted limitations of traditional disease monitoring methods. Here we demonstrate that circulating tumour DNA (ctDNA) is readily detectable in patients with CLL. Importantly, ctDNA does not simply mirror the genomic information contained within circulating malignant lymphocytes but instead parallels changes across different disease compartments following treatment with novel therapies. Serial ctDNA analysis allows clonal dynamics to be monitored over time and identifies the emergence of genomic changes associated with Richter's syndrome (RS). In addition to conventional disease monitoring, ctDNA provides a unique opportunity for non-invasive serial analysis of CLL for molecular disease monitoring. Disease monitoring of chronic lymphocytic leukaemia (CLL) is a challenge. Here, the authors show that serial ctDNA analysis in 32 CLL patients allows monitoring of clonal dynamics over time, and identifies the emergence of genomic changes associated with Richter's syndrome.
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116
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Guo A, Lu P, Coffey G, Conley P, Pandey A, Wang YL. Dual SYK/JAK inhibition overcomes ibrutinib resistance in chronic lymphocytic leukemia: Cerdulatinib, but not ibrutinib, induces apoptosis of tumor cells protected by the microenvironment. Oncotarget 2017; 8:12953-12967. [PMID: 28088788 PMCID: PMC5355069 DOI: 10.18632/oncotarget.14588] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/01/2017] [Indexed: 11/25/2022] Open
Abstract
Ibrutinib (BTK inhibitor) has generated remarkable responses in CLL. However, the drug, to a large extent, does not cause cell death directly and does not eradicate CLL malignant clones. Inability to eradicate CLL has fostered resistance generation. Once patients become resistant, they do poorly with a median survival of 3-4 months. Novel therapeutic strategies are needed to prevent resistance, improve treatment outcome and ultimately cure the disease. Herein, we explore dual targeting of the BCR and JAK-STAT pathways with a novel single agent, cerdulatinib, which selectively inhibits both SYK (a BCR component) and JAK kinases. We demonstrated that cerdulatinib delivered potent tumor inhibition in 60 primary CLL patient samples, especially in those with poor prognostic indicators. Importantly, cerdulatinib, but not ibrutinib, is able to overcome the support of microenvironment and induces CLL cell death at clinically achievable concentrations. Notably, cerdulatinib blocked proliferation of ibrutinib-resistant primary CLL cells and of BTKC481S-transfected/ibrutinib-resistant lymphoma cells. These anti-tumor effects are well correlated with the inhibition of BCR and JAK-STAT signaling and downstream inhibition of the functions of AKT, ERK and NFκB. Collectively, our results show that simultaneous targeting of BCR and JAK-STAT pathways is a more effective strategy relative to single BTK inhibition.
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Affiliation(s)
- Ailin Guo
- Department of Pathology, Lymphoma Translational Pathology, University of Chicago, Chicago, IL, USA
| | - Pin Lu
- Department of Pathology, Lymphoma Translational Pathology, University of Chicago, Chicago, IL, USA
| | - Greg Coffey
- Portola Pharmaceuticals, Inc., South San Francisco, CA, USA
| | - Pamela Conley
- Portola Pharmaceuticals, Inc., South San Francisco, CA, USA
| | - Anjali Pandey
- Portola Pharmaceuticals, Inc., South San Francisco, CA, USA
| | - Y. Lynn Wang
- Department of Pathology, Lymphoma Translational Pathology, University of Chicago, Chicago, IL, USA
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117
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Robak T, Stilgenbauer S, Tedeschi A. Front-line treatment of CLL in the era of novel agents. Cancer Treat Rev 2017; 53:70-78. [DOI: 10.1016/j.ctrv.2016.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 12/22/2022]
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118
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Burger JA, Li KW, Keating MJ, Sivina M, Amer AM, Garg N, Ferrajoli A, Huang X, Kantarjian H, Wierda WG, O'Brien S, Hellerstein MK, Turner SM, Emson CL, Chen SS, Yan XJ, Wodarz D, Chiorazzi N. Leukemia cell proliferation and death in chronic lymphocytic leukemia patients on therapy with the BTK inhibitor ibrutinib. JCI Insight 2017; 2:e89904. [PMID: 28138560 DOI: 10.1172/jci.insight.89904] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND. Ibrutinib is an effective targeted therapy for patients with chronic lymphocytic leukemia (CLL) that inhibits Bruton's tyrosine kinase (BTK), a kinase involved in B cell receptor signaling. METHODS. We used stable isotopic labeling with deuterated water (2H2O) to measure directly the effects of ibrutinib on leukemia cell proliferation and death in 30 patients with CLL. RESULTS. The measured average CLL cell proliferation ("birth") rate before ibrutinib therapy was 0.39% of the clone per day (range 0.17%-1.04%); this decreased to 0.05% per day (range 0%-0.36%) with treatment. Death rates of blood CLL cells increased from 0.18% per day (average, range 0%-0.7%) prior to treatment to 1.5% per day (range 0%-3.0%) during ibrutinib therapy, and they were even higher in tissue compartments. CONCLUSIONS. This study provides the first direct in vivo measurements to our knowledge of ibrutinib's antileukemia actions, demonstrating profound and immediate inhibition of CLL cell proliferation and promotion of high rates of CLL cell death. TRIAL REGISTRATION. This trial was registered at clinicaltrials.gov (NCT01752426). FUNDING. This study was supported by a Cancer Center Support Grant (National Cancer Institute grant P30 CA016672), an NIH grant (CA081554) from the National Cancer Institute, MD Anderson's Moon Shots Program in CLL, and Pharmacyclics, an AbbVie company.
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Affiliation(s)
- Jan A Burger
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Michael J Keating
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | - Mariela Sivina
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | - Xuelin Huang
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | - William G Wierda
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan O'Brien
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas, USA
| | - Marc K Hellerstein
- Department of Nutritional Sciences and Toxicology, University of California, Berkeley, Berkeley, California, USA
| | | | | | - Shih-Shih Chen
- Karches Center for Chronic Lymphocytic Leukemia Research, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Xiao-Jie Yan
- Karches Center for Chronic Lymphocytic Leukemia Research, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Dominik Wodarz
- Department of Mathematics and Department of Ecology and Evolutionary Biology, University of California, Irvine, Irvine, California, USA
| | - Nicholas Chiorazzi
- Karches Center for Chronic Lymphocytic Leukemia Research, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York, USA
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Molica S, Montserrat E. CLL: when the target of treatment is disease-related symptoms. LANCET HAEMATOLOGY 2017; 4:e57-e58. [PMID: 28089237 DOI: 10.1016/s2352-3026(16)30186-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 11/25/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Stefano Molica
- Department Haematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Viale Pio X, 88100, Catanzaro, Italy.
| | - Emili Montserrat
- Institute of Haematology and Oncology, Hospital Clínic University of Barcelona, Barcelona, Spain
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120
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How I manage ibrutinib-refractory chronic lymphocytic leukemia. Blood 2017; 129:1270-1274. [PMID: 28096090 DOI: 10.1182/blood-2016-09-693598] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/12/2017] [Indexed: 01/01/2023] Open
Abstract
The introduction of the Bruton tyrosine kinase (BTK) inhibitor ibrutinib has dramatically changed the management of chronic lymphocytic leukemia (CLL). Although responses have been durable in the majority of patients, relapses do occur, especially in the high-risk patient population. Most relapses occur as the result of acquired mutations in BTK and PLCG2, which may facilitate success with alternative targeted therapies. As outcomes after ibrutinib relapse have been reported to be poor, specific strategies are needed for this patient population. Here, I discuss the diagnosis and management of ibrutinib-refractory CLL. The focus will be on common clinical scenarios that can be mistaken for relapse and how to accurately determine which patients are relapsing. Because there is no established standard of care, I discuss currently available options for standard therapy and existing clinical data. I also discuss new agents with the potential to be effective in patients refractory to ibrutinib. Finally, I discuss strategies for long-term disease control in this patient population.
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121
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Jain P, Keating M, Renner S, Cleeland C, Xuelin H, Gonzalez GN, Harris D, Li P, Liu Z, Veletic I, Rozovski U, Jain N, Thompson P, Bose P, DiNardo C, Ferrajoli A, O'Brien S, Burger J, Wierda W, Verstovsek S, Kantarjian H, Estrov Z. Ruxolitinib for symptom control in patients with chronic lymphocytic leukaemia: a single-group, phase 2 trial. LANCET HAEMATOLOGY 2017; 4:e67-e74. [PMID: 28089238 PMCID: PMC5356368 DOI: 10.1016/s2352-3026(16)30194-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/17/2022]
Abstract
Background Disease-related symptoms impair the quality of life of countless patients with chronic lymphocytic leukemia (CLL) who do not require systemic therapy. Currently available therapies are not specifically aimed at symptom control. Because stimulation of the B-cell receptor activates Janus kinase (JAK)-2 in CLL cells and the JAK2 inhibitor ruxolitinib improves symptoms of patients with myelofibrosis, we hypothesized that ruxolitinib would improve disease-related symptoms in CLL patients. Methods Ruxolitinib (10 mg twice daily) was administered to symptomatic CLL patients who did not require systemic therapy for CLL. Scores on the brief fatigue inventory (BFI), CLL module of the MD Anderson symptom inventory (MDASI) and symptom-associated interference in daily activities (interference score; IS), were assessed prior to treatment and after 3 months of treatment. Plasma cytokine/chemokine levels were measured at baseline and at 3 months. Findings Forty-one CLL patients (25 untreated and 16 previously treated) were enrolled. Thirty-two (78%) of the participants experienced ≥20% reduction in the average BFI score or in the average MDASI score. 59% of the participants had ≥2 units reduction in worst fatigue score in 24 hours as assessed by the BFI. The mean percentage reductions in BFI, MDASI, and IS scores were >42% (p<0.0001). Improvements in the three symptom scores correlated with reductions in levels of IL-6, C-reactive protein, CXCL10, osteopontin, TNF-α, ICAM-1/CD54, VCAM-1/CD106, and beta-2 microglobulin. Furthermore, treatment with ruxolitinib increased and then decreased lymphocyte counts to baseline levels or lower. Grade 3/4 cytopenias were recorded in three patients. Interpretation In CLL patients, ruxolitinib significantly improved disease-related symptoms, reduced cytokine and chemokine levels, and increased and then decreased lymphocyte counts, likely through mobilization followed by apoptosis of CLL cells. Further studies aimed at testing the therapeutic efficacy of ruxolitinib in CLL are warranted. Funding Supported by the Incyte Corp., MD Anderson Cancer Center Support Grant CA016672 and Award Number P01 CA049639 from the National Cancer Institute.
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Affiliation(s)
- Preetesh Jain
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Keating
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah Renner
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles Cleeland
- Symptom Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huang Xuelin
- Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Harris
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Li
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhiming Liu
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ivo Veletic
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uri Rozovski
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Phillip Thompson
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Burger
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Coutré SE, Furman RR, Flinn IW, Burger JA, Blum K, Sharman J, Jones J, Wierda W, Zhao W, Heerema NA, Johnson AJ, Tran A, Zhou C, Bilotti E, James DF, Byrd JC, O'Brien S. Extended Treatment with Single-Agent Ibrutinib at the 420 mg Dose Leads to Durable Responses in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. Clin Cancer Res 2017; 23:1149-1155. [PMID: 28073846 DOI: 10.1158/1078-0432.ccr-16-1431] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 07/28/2016] [Accepted: 08/03/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Ibrutinib, a first-in-class, once-daily, oral inhibitor of Bruton tyrosine kinase, promotes apoptosis, and inhibits B-cell proliferation, adhesion, and migration. Ibrutinib has demonstrated single-agent efficacy and acceptable tolerability at doses of 420 and 840 mg in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) who were treatment-naïve (TN) or had relapsed/refractory (R/R) CLL after ≥1 prior therapy in a phase Ib/II study (PCYC-1102). Subsequently, the ibrutinib 420 mg dose was approved in CLL.Experimental Design: We report data with 44 months of follow-up on 94 patients with TN and R/R CLL/SLL receiving ibrutinib 420 mg once-daily in PCYC-1102 and the long-term extension study PCYC-1103.Results: Ninety-four CLL/SLL patients (27 TN, 67 R/R) were treated with ibrutinib (420 mg/day). Patients with R/R disease had received a median of four prior therapies (range, 1-12). Responses were rapid and durable and median duration of response was not reached. Best overall response was 91% [85% TN (complete response, CR 26%) and 94% R/R (9% CR)]. Median progression-free survival (PFS) was not reached in either group. The 30-month PFS rate was 96% and 76% for TN and R/R patients, respectively. Ibrutinib was well tolerated with extended follow-up; rates of grade ≥3 cytopenias and fatigue, as well as discontinuations due to toxicities decreased over time.Conclusions: Single-agent ibrutinib at 420 mg once-daily resulted in durable responses and was well tolerated with up to 44 months follow-up in patients with TN and R/R CLL/SLL. Currently, 66% of patients continue on ibrutinib. Clin Cancer Res; 23(5); 1149-55. ©2017 AACR.
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Affiliation(s)
- Steven E Coutré
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, California.
| | - Richard R Furman
- Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ian W Flinn
- Sarah Cannon Research Institute, Nashville, Tennessee
| | - Jan A Burger
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jeff Sharman
- Willamette Valley Cancer Institute and Research Center/US Oncology Research, Springfield, Oregon
| | | | - William Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | | | - Anh Tran
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, California
| | | | | | | | - Susan O'Brien
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
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123
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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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124
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Brander DM. Rationale for combinatory chronic lymphocytic leukaemia treatment paradigms in the era of the B-cell receptor pathway and anti-apoptotic inhibitors: how do we mix, match, and move forward? Br J Haematol 2016; 176:337-340. [PMID: 27984636 DOI: 10.1111/bjh.14446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 10/11/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Danielle M Brander
- Division of Hematological Malignancies & Cellular Therapy, Department of Medicine, Duke University, Durham, NC, USA
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125
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Sharman JP, Farber CM, Mahadevan D, Schreeder MT, Brooks HD, Kolibaba KS, Fanning S, Klein L, Greenwald DR, Sportelli P, Miskin HP, Weiss MS, Burke JM. Ublituximab (TG-1101), a novel glycoengineered anti-CD20 antibody, in combination with ibrutinib is safe and highly active in patients with relapsed and/or refractory chronic lymphocytic leukaemia: results of a phase 2 trial. Br J Haematol 2016; 176:412-420. [PMID: 27982425 PMCID: PMC5299538 DOI: 10.1111/bjh.14447] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/22/2016] [Indexed: 02/01/2023]
Abstract
Ibrutinib is effective in patients with chronic lymphocytic leukaemia (CLL); however, treatment resistance remains a problem. Ublituximab is a novel, glycoengineered anti-CD20 monoclonal antibody with single-agent activity in relapsed CLL. We report the results of a phase 2 study evaluating combination therapy with ibrutinib and ublituximab in patients with relapsed or refractory CLL. Patients received ibrutinib 420 mg once daily. Ublituximab was administered on days 1, 8 and 15 of cycle 1 followed by day 1 of cycles 2-6. Response assessments were completed at cycles 3 and 6; patients then continued on ibrutinib monotherapy per standard of care. Forty-one of 45 enrolled patients were evaluable for efficacy. Safety was consistent with prior experience for each drug, with infusion reactions the most prevalent adverse event. Combination therapy resulted in an overall response rate (ORR) of 88% at 6 months. In the 20 patients with high-risk features (17p or 11q deletions or TP53 mutation) and evaluable for efficacy, the ORR was 95%, with three patients (15%) achieving negative minimal residual disease. Median time to response was 8 weeks. Ublituximab in combination with ibrutinib resulted in rapid and high response rates. The long-term clinical benefit of ublituximab will be defined by an ongoing phase 3 trial (NCT 02301156).
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Affiliation(s)
- Jeff P Sharman
- Willamette Valley Cancer Institute, Springfield, OR, USA.,US Oncology Research, Morristown, NJ, USA
| | | | - Daruka Mahadevan
- West Cancer Center/University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Heather D Brooks
- US Oncology Research, Morristown, NJ, USA.,Blue Ridge Cancer Care, Blacksburg, VA, USA
| | - Kathryn S Kolibaba
- US Oncology Research, Morristown, NJ, USA.,Compass Oncology, Vancouver, WA, USA
| | - Suzanne Fanning
- US Oncology Research, Morristown, NJ, USA.,Greenville Health System Cancer Institute, Greenville, SC, USA
| | - Leonard Klein
- US Oncology Research, Morristown, NJ, USA.,Illinois Cancer Specialists, Niles, IL, USA
| | - Daniel R Greenwald
- US Oncology Research, Morristown, NJ, USA.,Cancer Center of Santa Barbara, Santa Barbara, CA, USA
| | | | | | | | - John M Burke
- US Oncology Research, Morristown, NJ, USA.,Rocky Mountain Cancer Centers, Aurora, CO, USA
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126
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Vela CM, McBride A, Jaglowski SM, Andritsos LA. Ibrutinib for treatment of chronic lymphocytic leukemia. Am J Health Syst Pharm 2016; 73:367-75. [PMID: 26953281 DOI: 10.2146/ajhp140760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The pharmacology, pharmacokinetics, pharmacodynamics, clinical efficacy, and safety of ibrutinib are described. SUMMARY Ibrutinib is a first-in-class oral inhibitor of Bruton tyrosine kinase (BTK) approved for treatment of relapsed chronic lymphocytic leukemia (CLL). Ibrutinib blocks downstream signaling of the B-cell receptor, disrupting stromal microenvironment interactions and B-cell cytokine signaling. BTK inhibition has been shown to be effective in relapsed or refractory CLL. A recent Phase III study evaluated ibrutinib (420 mg daily) versus ofatumumab (consistent with labeling) in relapsed or refractory CLL with a primary endpoint of progression free survival (PFS, n = 391). After a median follow-up period of 9.4 months, a PFS was not attained in ibrutinib-treated individuals with and without deletion 17p. In contrast, ofatumumab-treated individuals experienced a PFS of 8.1 months and those with deletion 17p experienced a PFS of 5.8 months. Major hemorrhage was reported in 2 (1%) patients treated with ibrutinib, and a total of 8 (4%) patients discontinued treatment due to toxicity or adverse reactions. Partial response or partial response with lymphocytosis was achieved in 63% of ibrutinib-treated individuals as determined by independent assessments. Overall, ibrutinib reduced the rate of mortality by 57%. CONCLUSION Ibrutinib is a first-in-class, orally active, irreversible BTK inhibitor with a novel mechanism of action. This unique mechanism of action and high overall response rates observed in clinical trials make ibrutinib an attractive second-line option in patients who have disease progression while receiving monoclonal antibody therapy or chemoimmunotherapy.
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Affiliation(s)
- Cory M Vela
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
| | - Ali McBride
- University of Arizona Cancer Center, Tuscon, AZ
| | - Samantha M Jaglowski
- Division of Hematology, Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Leslie A Andritsos
- Division of Hematology, Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Solove Research Institute, Columbus, OH
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127
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Eichhorst B, Hallek M. Prognostication of chronic lymphocytic leukemia in the era of new agents. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:149-155. [PMID: 27913474 PMCID: PMC6142472 DOI: 10.1182/asheducation-2016.1.149] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The prognosis of chronic lymphocytic leukemia (CLL) is very heterogeneous. Therefore, a plethora of prognostic factors has been identified to allow a better prediction of the individual prognosis of a given patient. The clinical staging systems by Rai and Binet have been the backbone of clinical management for several decades. The advent of genetic and biochemical markers, as well as next-generation sequencing has provided several markers that can predict the prognosis of patients with CLL. Using this knowledge, several scores have been created to improve predicting overall survival and/or treatment-free survival. These prognostic scores were developed in the era of chemotherpay/chemoimmunotherapy. Therefore, they now need to be tested with novel agents. However, despite tremendously improved therapeutic options, CLL patients with TP53 dysfunction or a complex karyotype remain at very high risk and seem to have a shorter (treatment-free) survival. The recently published international prognostic index (CLL IPI) incorporates most of these factors and provides a tool to analyze outcome in the modern era of targeted therapies.
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MESH Headings
- Biomarkers, Tumor/genetics
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Survival Rate
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
- Barbara Eichhorst
- Department I for Internal Medicine and Centre of Integrated Oncology, and
| | - Michael Hallek
- Department I for Internal Medicine and Centre of Integrated Oncology, and
- CECAD—Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Diseases, University of Cologne, Cologne, Germany
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128
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Cheson BD, Ansell S, Schwartz L, Gordon LI, Advani R, Jacene HA, Hoos A, Barrington SF, Armand P. Refinement of the Lugano Classification lymphoma response criteria in the era of immunomodulatory therapy. Blood 2016; 128:2489-2496. [PMID: 27574190 DOI: 10.1182/blood-2016-05-718528] [Citation(s) in RCA: 303] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 08/16/2016] [Indexed: 12/18/2022] Open
Abstract
Uniformly adopted response criteria are essential for assessment of therapies incorporating conventional chemotherapy and chemoimmunotherapy regimens. Recently, immunomodulatory agents, such as immune checkpoint inhibitors, have demonstrated impressive activity in a broad range of lymphoma histologies. However, these agents may be associated with clinical and imaging findings during treatment suggestive of progressive disease (PD) despite evidence of clinical benefit (eg, tumor flare or pseudo-progression). Considering this finding as PD could lead to patients being prematurely removed from a treatment from which they actually stand to benefit. This phenomenon has been well described with checkpoint blockade therapy in solid tumors and anecdotally seen in lymphoma as well. To address this issue in the context of lymphoma immunomodulatory therapy, a workshop was convened to provide provisional recommendations to modify current response criteria in patients receiving these and future agents in clinical trials. The term "indeterminate response" was introduced to identify such lesions until confirmed as flare/pseudo-progression or true PD by either biopsy or subsequent imaging.
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Affiliation(s)
- Bruce D Cheson
- Division of Hematology-Oncology, Department of Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington, DC
| | | | - Larry Schwartz
- Department of Radiology, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Leo I Gordon
- Division of Hematology-Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ranjana Advani
- Department of Medicine/Oncology, Stanford University, Stanford, CA
| | | | - Axel Hoos
- Oncology R&D, GlaxoSmithKline, Collegeville, PA; and
| | - Sally F Barrington
- Department of Nuclear Medicine, PET Imaging Centre at St. Thomas', London, United Kingdom
| | - Philippe Armand
- Department of Imaging, Dana-Farber Cancer Institute, Boston, MA
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129
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Welt RS, Welt JA, Kostyal D, Gangadharan YD, Raymond V, Welt S. Specificity and biologic activities of novel anti-membrane IgM antibodies. Oncotarget 2016; 7:74701-74723. [PMID: 27732950 PMCID: PMC5342696 DOI: 10.18632/oncotarget.12506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 09/24/2016] [Indexed: 12/03/2022] Open
Abstract
The concept that the B-cell Receptor (BCR) initiates a driver pathway in lymphoma-leukemia has been clinically validated. Previously described unique BCR Ig-class-specific sequences (proximal domains (PDs)), are not expressed in serum Ig (sIg). As a consequence of sequence and structural differences in the membrane IgM (mIgM) µ-Constant Domain 4, additional epitopes distinguish mIgM from sIgM. mAbs generated to linear and conformational epitopes, restricted to mIgM and not reacting with sIgM, were generated despite the relative hydrophobicity of the PDm sequence. Anti-PD mAbs (mAb1, mAb2, and mAb3) internalize mIgM. Anti-mIgM mAb4, which recognizes a distinct non-ligand binding site epitope, mediates mIgM internalization, and in low-density cultures, growth inhibition, anti-clonogenic activity, and apoptosis. We show that mAb-mediated mIgM internalization generally does not interrupt BCR-directed cell growth, however, mAb4 binding to a non-ligand binding site in the mIgM PDm-μC4 domain induces both mIgM internalization and anti-tumor effects. BCR micro-clustering in many B-cell leukemia and lymphoma lines is demonstrated by SEM micrographs using these new mAb reagents. mAb4 is a clinical candidate as a mediator of inhibition of the BCR signaling pathway. As these agents do not bind to non-mIgM B-cells, nor cross-react to non-lymphatic tissues, they may spare B-cell/normal tissue destruction as mAb-drug conjugates.
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MESH Headings
- Animals
- Antibodies, Anti-Idiotypic/immunology
- Antibodies, Anti-Idiotypic/pharmacology
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/pharmacology
- Antibody Specificity/immunology
- Cell Line, Tumor
- Enzyme-Linked Immunosorbent Assay
- Epitope Mapping
- Epitopes/chemistry
- Epitopes/immunology
- Epitopes/metabolism
- Humans
- Hybridomas/immunology
- Leukemia, B-Cell/immunology
- Leukemia, B-Cell/metabolism
- Lymphoma, B-Cell/immunology
- Lymphoma, B-Cell/metabolism
- Mice
- Peptides/immunology
- Protein Binding
- Protein Transport
- Receptors, Antigen, B-Cell/antagonists & inhibitors
- Receptors, Antigen, B-Cell/chemistry
- Receptors, Antigen, B-Cell/immunology
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Affiliation(s)
| | | | | | | | - Virginia Raymond
- Welt Bio-Molecular Pharmaceutical, LLC., Armonk, NY, USA
- Biogent, LLC., Armonk, NY, USA
| | - Sydney Welt
- Welt Bio-Molecular Pharmaceutical, LLC., Armonk, NY, USA
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130
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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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131
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Abstract
Activation of the Bruton tyrosine kinase (BTK) pathway plays an important role in the pathophysiology of a number of B-cell lymphoproliferative disorders (LPDs). A number of preclinical studies support inhibiting BTK as a mechanism to treat LPDs. Clinically, BTK inhibitors, specifically ibrutinib, have shown to be safe and effective on treating patients with indolent B-cell lymphomas and chronic lymphocytic leukemia (CLL). Ibrutinib has recently gained approval for the treatment of patients with mantle cell lymphoma, Waldenström macroglobulinemia, and CLL. Ongoing clinical trials are investigating ibrutinib and other BTK inhibitors alone or in combination for the treatment of mantle cell lymphoma, Waldenström macroglobulinemia, CLL, activated B-cell-type diffuse large B-cell lymphoma, and follicular lymphoma, among others. The objective of this review is to succinctly summarize the current body of evidence on BTK inhibition in patients with B-cell LPDs.
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132
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Combination of Targeted Drugs to Control Chronic Lymphocytic Leukemia: Harnessing the Power of New Monoclonal Antibodies in Combination With Ibrutinib. Cancer J 2016; 22:62-6. [PMID: 26841018 DOI: 10.1097/ppo.0000000000000174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The landscape of treatment for chronic lymphocytic leukemia is rapidly changing at present. Considerable improvement has been achieved with the introduction of the anti-CD20 antibodies, and chemoimmunotherapy has now become an established standard for patients without the high-risk features del(17p)/TP53 mutation. Also, the outcome of patients with these adverse genetic aberrations was dramatically improved with the introduction of the kinase inhibitors ibrutinib and idelalisib. Different combinations of these and additional novel agents are currently evaluated in clinical trials. The combination of the Bruton tyrosine kinase inhibitor ibrutinib with an anti-CD20 antibody is an attractive option, because both drugs act synergistically: ibrutinib redistributes the CLL cells from their homing organs to the peripheral blood, and obinutuzumab eliminates the leukemic cells in the blood with particular efficiency. Adding the Bcl-2 antagonist venetoclax could further intensify the treatment of CLL. This combination might hold the potential to achieve a deep remission with an eradication of residual CLL cells and thus lead to long-term remissions of CLL.
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Guo A, Lu P, Galanina N, Nabhan C, Smith SM, Coleman M, Wang YL. Heightened BTK-dependent cell proliferation in unmutated chronic lymphocytic leukemia confers increased sensitivity to ibrutinib. Oncotarget 2016; 7:4598-610. [PMID: 26717038 PMCID: PMC4826229 DOI: 10.18632/oncotarget.6727] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/25/2015] [Indexed: 12/21/2022] Open
Abstract
In chronic lymphocytic leukemia (CLL), patients with unmutated immunoglobulin heavy chain variable region gene (UM-CLL) have worse outcomes than mutated CLL (M-CLL) following chemotherapy or chemoimmunotherapy. However, in the era of BCR-targeted therapies, the adverse prognostic impact of unmutated IGHV seems to be diminishing, and there are clinical datasets showing unexpected improved responses in UM-CLL. We investigated the biological differences of BTK activity between these subgroups and further compared the impact of ibrutinib on molecular and cellular behaviors. Immunoblotting analysis revealed that phosphorylated active BTK is significantly higher in UM-CLL. Moreover, UM-CLL, compared to M-CLL, displayed a much higher proliferative capacity that was correlated with higher phospho-BTK and greater sensitivity to ibrutinib. In addition, BTK depletion with siRNA led to a more prominent reduction in the proliferation of UM-CLL, suggesting that elevated BTK activity is responsible for increased cell proliferation. Further, cell signaling activity by multiple measurements was consistently higher in UM-CLL accompanied by a higher sensitivity to ibrutinib. These studies link UM-CLL to elevated BCR signaling, heightened BTK-dependent cell proliferation and increased sensitivity to ibrutinib. The prognostic significance of IGHV mutation should be reevaluated in the era of new therapies targeting BCR signaling.
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Affiliation(s)
- Ailin Guo
- Division of Genomic and Molecular Pathology, Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Pin Lu
- Division of Genomic and Molecular Pathology, Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Natalie Galanina
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Chadi Nabhan
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Sonali M Smith
- Department of Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, USA
| | - Morton Coleman
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Y Lynn Wang
- Division of Genomic and Molecular Pathology, Department of Pathology, University of Chicago, Chicago, IL, USA
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Bohn JP, Wanner D, Steurer M. Ibrutinib for relapsed refractory hairy cell leukemia variant. Leuk Lymphoma 2016; 58:1224-1226. [PMID: 27733095 DOI: 10.1080/10428194.2016.1239262] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jan-Paul Bohn
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria
| | - David Wanner
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria
| | - Michael Steurer
- a Department of Internal Medicine V , Medical University of Innsbruck , Innsbruck , Austria
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Bose P, Gandhi VV, Keating MJ. Pharmacokinetic and pharmacodynamic evaluation of ibrutinib for the treatment of chronic lymphocytic leukemia: rationale for lower doses. Expert Opin Drug Metab Toxicol 2016; 12:1381-1392. [PMID: 27686109 DOI: 10.1080/17425255.2016.1239717] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Ibrutinib, a first-in-class covalent inhibitor of Bruton's tyrosine kinase (BTK), is approved in many countries for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL) and for previously untreated disease with a 17p deletion and, most recently, as a frontline therapy for CLL. In controlled trials in CLL, ibrutinib produced high response rates and improved survival in both the frontline and relapsed settings. While ibrutinib controls CLL with impressive efficacy, it only infrequently induces complete remissions, particularly of relapsed CLL, and does not eradicate minimal residual disease. Finally, ibrutinib is extremely expensive, has off-target toxicities, and requires indefinite therapy. Areas covered: In this article, we provide an overview of the CLL therapeutic landscape and discuss the pharmacokinetic and pharmacodynamic aspects of ibrutinib. Major clinical trials of ibrutinib in CLL are summarized, and its safety profile explored. Expert opinion: Ibrutinib represents a transformative advance in CLL management and has validated BTK as a therapeutic target in this disease, but has some limitations, leading to the emergence of other BTK inhibitors and mechanism-based combination strategies. Given complete BTK occupancy at lower doses of ibrutinib and declining levels of BTK on ibrutinib therapy, lower doses of ibrutinib in CLL are being explored.
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Affiliation(s)
- Prithviraj Bose
- a Department of Leukemia , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Varsha V Gandhi
- a Department of Leukemia , University of Texas MD Anderson Cancer Center , Houston , TX , USA.,b Department of Experimental Therapeutics , University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Michael J Keating
- a Department of Leukemia , University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Amin NA, Balasubramanian S, Saiya-Cork K, Shedden K, Hu N, Malek SN. Cell-Intrinsic Determinants of Ibrutinib-Induced Apoptosis in Chronic Lymphocytic Leukemia. Clin Cancer Res 2016; 23:1049-1059. [PMID: 27535981 DOI: 10.1158/1078-0432.ccr-15-2921] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 07/07/2016] [Accepted: 08/08/2016] [Indexed: 01/18/2023]
Abstract
Purpose: Ibrutinib, a Bruton tyrosine kinase (BTK) inhibitor, is approved for the treatment of relapsed chronic lymphocytic leukemia (CLL) and CLL with del17p. Mechanistically, ibrutinib interferes with B-cell receptor (BCR) signaling as well as multiple CLL cell-to-microenvironment interactions. Given the importance of ibrutinib in the management of CLL, a deeper understanding of factors governing sensitivity and resistance is warranted.Experimental Design: We studied 48 longitudinally sampled paired CLL samples, 42 of which were procured before and after standard CLL chemotherapies, and characterized them for well-studied CLL molecular traits as well as by whole-exome sequencing and SNP 6.0 array profiling. We exposed these samples to 0.25 to 5 μmol/L of ibrutinib ex vivo and measured apoptosis fractions as well as BCR signaling by immunoblotting. We disrupted TP53 in HG3, PGA1, and PG-EBV cell lines and measured BCR signaling and ibrutinib responses.Results: CLL samples demonstrated a surprisingly wide range of ex vivo sensitivities to ibrutinib, with IC50 values ranging from 0.4 to 9.7 μmol/L. Unmutated IGVH status, elevated ZAP70 expression, and trisomy 12 were associated with heightened sensitivity to ibrutinib treatment. Five CLL samples were substantially more resistant to ibrutinib following relapse from chemotherapy; of these, three had acquired a del17p/TP53-mutated status. A validation sample of 15 CLL carrying TP53 mutations, of which 13 carried both del17p and a TP53 mutation, confirmed substantially less sensitivity to ibrutinib-induced apoptosis.Conclusions: This study identifies that CLL harboring del17p/TP53-mutated cells are substantially less sensitive to ibrutinib-induced apoptosis than del17p/TP53 wild-type cells. Clin Cancer Res; 23(4); 1049-59. ©2016 AACR.
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Affiliation(s)
- Nisar A Amin
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Kamlai Saiya-Cork
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kerby Shedden
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Nan Hu
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Sami N Malek
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan.
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Surface IgM expression and function are associated with clinical behavior, genetic abnormalities, and DNA methylation in CLL. Blood 2016; 128:816-26. [DOI: 10.1182/blood-2016-03-707786] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/06/2016] [Indexed: 02/08/2023] Open
Abstract
Key Points
High sIgM level is a potential key factor associated with poorer clinical outcome in CLL. Genetic and epigenetic features influence sIgM levels and function in CLL.
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Marini BL, Samanas L, Perissinotti AJ. Expanding the armamentarium for chronic lymphocytic leukemia: A review of novel agents in the management of chronic lymphocytic leukemia. J Oncol Pharm Pract 2016; 23:502-517. [DOI: 10.1177/1078155216656929] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Treatment options for chronic lymphocytic leukemia, the most common leukemia in the United States, have expanded rapidly in recent years. While traditional chemoimmunotherapy still remains a mainstay for young, fit patients, a number of novel targeted therapies have emerged that have changed the therapeutic landscape. Two innovative anti-CD20 monoclonal antibodies, obinutuzumab and ofatumomamab, have demonstrated activity in chronic lymphocytic leukemia and represent well-tolerated options in upfront management of elderly patients or in those with significant comorbidities. Agents targeting the B-cell receptor pathway, ibrutinib and idelalisib, have excellent activity in chronic lymphocytic leukemia, particularly in those patients with 17p deletions, in which responses to chemoimmunotherapy are traditionally dismal. Venetoclax (ABT-199), the recently FDA-approved BCL2 inhibitor, as well as several other agents and therapy combinations in the pipeline offer great promise for patients with chronic lymphocytic leukemia, particularly in the relapsed/refractory setting. This article comprehensively reviews the data for novel agents in chronic lymphocytic leukemia, including the pharmacology of therapies, unique toxicities, and other practical management considerations for clinicians.
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Affiliation(s)
- Bernard L Marini
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System and College of Pharmacy, USA
| | - Lisa Samanas
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System and College of Pharmacy, USA
| | - Anthony J Perissinotti
- Department of Pharmacy Services and Clinical Sciences, University of Michigan Health System and College of Pharmacy, USA
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Routledge DJM, Bloor AJC. Recent advances in therapy of chronic lymphocytic leukaemia. Br J Haematol 2016; 174:351-67. [DOI: 10.1111/bjh.14184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
| | - Adrian J. C. Bloor
- Department of Haematology; The Christie NHS Foundation Trust; Manchester UK
- University of Manchester; Manchester UK
- Manchester Academic Health Science Centre; Manchester UK
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Frustaci AM, Montillo M, Picardi P, Mazzucchelli M, Cairoli R, Tedeschi A. Paving the way for new agents; is standard chemotherapy part of the treatment paradigm for chronic lymphocytic leukemia in the future? Expert Rev Hematol 2016; 9:679-93. [DOI: 10.1080/17474086.2016.1191943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Maddalena Mazzucchelli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
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Vitale C, Burger JA. Chronic lymphocytic leukemia therapy: new targeted therapies on the way. Expert Opin Pharmacother 2016; 17:1077-89. [PMID: 26988407 PMCID: PMC4955400 DOI: 10.1517/14656566.2016.1168401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/10/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The critical role of the tissue microenvironment and B-cell receptor (BCR) signaling in chronic lymphocytic leukemia (CLL) pathogenesis, and the clinical success of targeted agents that disrupt BCR signaling are currently changing the CLL landscape. Three new drugs were recently approved for CLL therapy, and other agents are in late development. AREAS COVERED In this review, we summarize data on promising new targeted drugs for CLL. The heterogeneous mechanisms of actions of these molecules are described, such as the inhibition of BCR signaling, direct targeting of CD20 molecules on the CLL cell surface, and BCL-2 inhibition. We present preclinical and clinical data from phase I to III studies in order to describe efficacy and side effect profile of these new drugs. Data are derived from peer-reviewed articles indexed in PubMed and from abstracts presented at major international meetings. EXPERT OPINION Ibrutinib and idelalisib are challenging the role of chemo-immunotherapy in CLL therapy in the frontline and relapsed disease settings. High-risk CLL patients particularly benefit from these new agents. Venetoclax and obinutuzumab are other effective agents added to our therapeutic armamentarium. Studies to better define the optimal use of these drugs, alone, or rather in combination or sequenced are underway.
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Affiliation(s)
- Candida Vitale
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jan A Burger
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
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Allen JC, Talab F, Slupsky JR. Targeting B-cell receptor signaling in leukemia and lymphoma: how and why? Int J Hematol Oncol 2016; 5:37-53. [PMID: 30302202 DOI: 10.2217/ijh-2016-0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 05/13/2016] [Indexed: 01/04/2023] Open
Abstract
B-lymphocytes are dependent on B-cell receptor (BCR) signaling for the constant maintenance of their physiological function, and in many B-cell malignancies this signaling pathway is prone to aberrant activation. This understanding has led to an ever-increasing interest in the signaling networks activated following ligation of the BCR in both normal and malignant cells, and has been critical in establishing an array of small molecule inhibitors targeting BCR-induced signaling. By dissecting how different malignancies signal through BCR, researchers are contributing to the design of more customized therapeutics which have greater efficacy and lower toxicity than previous therapies. This allows clinicians access to an array of approaches to best treat patients whose malignancies have BCR signaling as a driver of pathogenesis.
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Affiliation(s)
- John C Allen
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GE, UK.,Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - Fatima Talab
- Redx Oncology Plc, Duncan Building, Royal Liverpool University Hospital, Daulby Street, Liverpool, L69 3GA, UK.,Redx Oncology Plc, Duncan Building, Royal Liverpool University Hospital, Daulby Street, Liverpool, L69 3GA, UK
| | - Joseph R Slupsky
- Department of Molecular & Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK.,Department of Molecular & Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Ashton Street, Liverpool, L69 3GE, UK
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First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol 2016; 17:928-942. [PMID: 27216274 DOI: 10.1016/s1470-2045(16)30051-1] [Citation(s) in RCA: 436] [Impact Index Per Article: 54.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/09/2016] [Accepted: 03/29/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab is the standard therapy for physically fit patients with advanced chronic lymphocytic leukaemia. This international phase 3 study compared the efficacy and tolerance of the standard therapy with a potentially less toxic combination consisting of bendamustine and rituximab. METHODS Treatment-naive fit patients with chronic lymphocytic leukaemia (aged 33-81 years) without del(17p) were enrolled after undergoing a central screening process. Patients were randomly assigned (1:1) with a computer-generated randomisation list using randomly permuted blocks with a block size of eight and were stratified according to participating country and Binet stage. Patients were allocated to receive six cycles of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days or to intravenous bendamustine (90 mg/m(2) per day) for the first 2 days of each cycle. Rituximab 375 mg/m(2) was given intravenously in both groups on day 0 of cycle 1 and subsequently was given at 500 mg/m(2) during the next five cycles on day 1. The primary endpoint was progression-free survival with the objective to assess non-inferiority of bendamustine and rituximab to the standard therapy. We aimed to show that the 2-year progression-free survival with bendamustine and rituximab was not 67·5% or less with a corresponding non-inferiority margin of 1·388 for the hazard ratio (HR) based on the 90·4% CI. The final analysis was done by intention to treat. The study is registered with ClinicalTrials.gov, number NCT%2000769522. FINDINGS 688 patients were recruited between Oct 2, 2008, and July 11, 2011, of which 564 patients who met inclusion criteria were randomly assigned. 561 patients were included in the intention-to-treat population: 282 patients in the fludarabine, cyclophosphamide, and rituximab group and 279 in the bendamustine and rituximab group. After a median observation time of 37·1 months (IQR 31·0-45·5) median progression-free survival was 41·7 months (95% CI 34·9-45·3) with bendamustine and rituximab and 55·2 months (95% CI not evaluable) with fludarabine, cyclophosphamide, and rituximab (HR 1·643, 90·4% CI 1·308-2·064). As the upper limit of the 90·4% CI was greater than 1·388 the null hypothesis for the corresponding non-inferiority hypothesis was not rejected. Severe neutropenia and infections were more frequently observed with fludarabine, cyclophosphamide, and rituximab (235 [84%] of 279 vs 164 [59%] of 278, and 109 [39%] vs 69 [25%], respectively) during the study. The increased frequency of infectious complications with fludarabine, cyclophosphamide, and rituximab was more pronounced in patients older than 65 years. INTERPRETATION The combination of fludarabine, cyclophosphamide, and rituximab remains the standard front-line therapy in fit patients with chronic lymphocytic leukaemia, but bendamustine and rituximab is associated with less toxic effects. FUNDING Roche Pharma AG, Mundipharma, German Federal Ministry of Education and Research.
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Ntoufa S, Papakonstantinou N, Apollonio B, Gounari M, Galigalidou C, Fonte E, Anagnostopoulos A, Belessi C, Muzio M, Ghia P, Stamatopoulos K. B Cell Anergy Modulated by TLR1/2 and the miR-17∼92 Cluster Underlies the Indolent Clinical Course of Chronic Lymphocytic Leukemia Stereotyped Subset #4. THE JOURNAL OF IMMUNOLOGY 2016; 196:4410-7. [PMID: 27059597 DOI: 10.4049/jimmunol.1502297] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 03/15/2016] [Indexed: 01/09/2023]
Abstract
Chronic lymphocytic leukemia (CLL) patients assigned to stereotyped subset #4 (mutated IGHV4-34/IGKV2-30 BCR Ig) display a particularly indolent disease course. Immunogenetic studies of the clonotypic BCR Ig of CLL subset #4 suggested a resemblance with B cells rendered anergic through chronic autoantigenic stimulation. In this article, we provide experimental evidence that subset #4 CLL cells show low IgG levels, constitutive ERK1/2 activation, and fail to either release intracellular Ca(2+) or activate MAPK signaling after BCR cross-linking, thus displaying a signature of B cell anergy at both biochemical and functional levels. Interestingly, TLR1/2 triggering restored BCR functionality, likely breaching the anergic state, and this was accompanied by induction of the miR-17∼92 cluster, whose members target critical BCR-associated molecules, including MAPKs. In conclusion, we demonstrate BCR anergy in CLL subset #4 and implicate TLR signaling and the miR-17∼92 cluster in the regulation of the anergic state. This detailed signaling profiling of subset #4 has implications for advanced understanding of the complex regulation of intracellular signaling pathways in CLL, currently a major therapeutic target of the disease.
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Affiliation(s)
- Stavroula Ntoufa
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki 57001, Greece; Hematology Department and Hematopoietic Cell Transplantation Unit, George Papanikolaou Hospital, Thessaloniki 57010, Greece
| | - Nikos Papakonstantinou
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki 57001, Greece; Hematology Department and Hematopoietic Cell Transplantation Unit, George Papanikolaou Hospital, Thessaloniki 57010, Greece
| | - Benedetta Apollonio
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Maria Gounari
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Chrysi Galigalidou
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki 57001, Greece
| | - Eleonora Fonte
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Achilles Anagnostopoulos
- Hematology Department and Hematopoietic Cell Transplantation Unit, George Papanikolaou Hospital, Thessaloniki 57010, Greece
| | - Chrysoula Belessi
- Hematology Department, Nikea General Hospital, Pireaus 18454, Greece
| | - Marta Muzio
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy
| | - Paolo Ghia
- Division of Experimental Oncology, IRCCS San Raffaele Scientific Institute, Milan 20132, Italy; Lymphoma Unit, Department of Onco-Hematology, Università Vita-Salute San Raffaele, Milan 20132, Italy; and
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki 57001, Greece; Hematology Department and Hematopoietic Cell Transplantation Unit, George Papanikolaou Hospital, Thessaloniki 57010, Greece; Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala 75105, Sweden
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Blachly JS, Byrd JC, Grever M. Cyclin-dependent kinase inhibitors for the treatment of chronic lymphocytic leukemia. Semin Oncol 2016; 43:265-73. [DOI: 10.1053/j.seminoncol.2016.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lamothe B, Wierda WG, Keating MJ, Gandhi V. Carfilzomib Triggers Cell Death in Chronic Lymphocytic Leukemia by Inducing Proapoptotic and Endoplasmic Reticulum Stress Responses. Clin Cancer Res 2016; 22:4712-26. [PMID: 27026200 DOI: 10.1158/1078-0432.ccr-15-2522] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 03/16/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE Carfilzomib, while active in B-cell neoplasms, displayed heterogeneous response in chronic lymphocytic leukemia (CLL) samples from patients and showed interpatient variability to carfilzomib-induced cell death. To understand this variability and predict patients who would respond to carfilzomib, we investigated the mechanism by which carfilzomib induces CLL cell death. EXPERIMENTAL DESIGN Using CLL patient samples and cell lines, complementary knockdown and knockout cells, and carfilzomib-resistant cell lines, we evaluated changes in intracellular networks to identify molecules responsible for carfilzomib's cytotoxic activity. Lysates from carfilzomib-treated cells were immunoblotted for molecules involved in ubiquitin, apoptotic, and endoplasmic reticulum (ER) stress response pathways and results correlated with carfilzomib cytotoxic activity. Coimmunoprecipitation and pull-down assays were performed to identify complex interactions among MCL-1, Noxa, and Bak. RESULTS Carfilzomib triggered ER stress and activation of both the intrinsic and extrinsic apoptotic pathways through alteration of the ubiquitin proteasome pathway. Consequently, the transcription factor CCAAT/enhancer-binding protein homology protein (CHOP) accumulated in response to carfilzomib, and CHOP depletion conferred protection against cytotoxicity. Carfilzomib also induced accumulation of MCL-1 and Noxa, whereby MCL-1 preferentially formed a complex with Noxa and consequently relieved MCL-1's protective effect on sequestering Bak. Accordingly, depletion of Noxa or both Bak and Bax conferred protection against carfilzomib-induced cell death. CONCLUSIONS Collectively, carfilzomib induced ER stress culminating in activation of intrinsic and extrinsic caspase pathways, and we identified the CHOP protein level as a biomarker that could predict sensitivity to carfilzomib in CLL. Clin Cancer Res; 22(18); 4712-26. ©2016 AACR.
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MESH Headings
- Adult
- Aged
- Antineoplastic Agents/pharmacology
- Apoptosis/drug effects
- Ataxia Telangiectasia Mutated Proteins/metabolism
- Biomarkers
- Cell Line, Tumor
- Endoplasmic Reticulum Stress/drug effects
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Middle Aged
- Mutation
- Oligopeptides/pharmacology
- Proteasome Endopeptidase Complex/metabolism
- Protein Binding
- Transcription Factor CHOP/metabolism
- Ubiquitinated Proteins/metabolism
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Affiliation(s)
- Betty Lamothe
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas. Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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147
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Jeyakumar D, O'Brien S. B cell receptor inhibition as a target for CLL therapy. Best Pract Res Clin Haematol 2016; 29:2-14. [DOI: 10.1016/j.beha.2016.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 07/13/2016] [Accepted: 08/04/2016] [Indexed: 01/22/2023]
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148
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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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149
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Current strategies to create tailored and risk-adapted therapies for CLL patients. Best Pract Res Clin Haematol 2016; 29:111-121. [DOI: 10.1016/j.beha.2016.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 08/01/2016] [Accepted: 08/04/2016] [Indexed: 11/22/2022]
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150
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Rauert-Wunderlich H, Rudelius M, Ott G, Rosenwald A. Targeting protein kinase C in mantle cell lymphoma. Br J Haematol 2016; 173:394-403. [PMID: 26914495 DOI: 10.1111/bjh.13973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/21/2015] [Indexed: 12/18/2022]
Abstract
Although targeting the Bruton tyrosine kinase (BTK) with ibrutinib has changed lymphoma treatment, patients with mantle cell lymphoma (MCL) remain incurable. In this study, we characterized a broad range of MCL cell lines and primary MCL cells with respect to the response to the BTK inhibitor, ibrutinib, and compared it with the response to the protein kinase C (PKC) inhibitor, sotrastaurin. At clinically relevant concentrations, each drug induced potent cell death only in the REC-1 cell line, which was accompanied by robust inhibition of AKT and ERK1/ERK2 (ERK1/2, also termed MAPK3/MAPK1) phosphorylation. In sensitive REC-1 cells, the drug-mediated impaired phosphorylation was obvious on the levels of B-cell receptor-induced and basal phosphorylation. Similar results were obtained in primary MCL cells with ibrutinib and in a subset with sotrastaurin. The various drug-resistant MCL cell lines showed very distinct responses in terms of basal AKT and ERK1/2 phosphorylation. Interestingly, targeting PKC and BTK at the same time led to ibrutinib-mediated rescue of a weak sotrastaurin-induced apoptosis in MINO cells. Additional targeting of AKT sensitized MINO cells to inhibitor-mediated cytotoxicity. In summary, MCL cells are heterogeneous in their response to BTK or PKC inhibition, indicating the need for even more individualized targeted treatment approaches in subsets of MCL patients.
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Affiliation(s)
- Hilka Rauert-Wunderlich
- Institute of Pathology, University of Würzburg and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
| | - Martina Rudelius
- Institute of Pathology, University of Würzburg and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
| | - German Ott
- Department of Clinical Pathology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.,Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Andreas Rosenwald
- Institute of Pathology, University of Würzburg and Comprehensive Cancer Center (CCC) Mainfranken, Würzburg, Germany
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