151
|
Blunt MD, Koehrer S, Dobson RC, Larrayoz M, Wilmore S, Hayman A, Parnell J, Smith LD, Davies A, Johnson PWM, Conley PB, Pandey A, Strefford JC, Stevenson FK, Packham G, Forconi F, Coffey GP, Burger JA, Steele AJ. The Dual Syk/JAK Inhibitor Cerdulatinib Antagonizes B-cell Receptor and Microenvironmental Signaling in Chronic Lymphocytic Leukemia. Clin Cancer Res 2017; 23:2313-2324. [PMID: 27697994 PMCID: PMC5417366 DOI: 10.1158/1078-0432.ccr-16-1662] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/01/2016] [Accepted: 09/10/2016] [Indexed: 11/16/2022]
Abstract
Purpose: B-cell receptor (BCR)-associated kinase inhibitors, such as ibrutinib, have revolutionized the treatment of chronic lymphocytic leukemia (CLL). However, these agents are not curative, and resistance is already emerging in a proportion of patients. IL4, expressed in CLL lymph nodes, can augment BCR signaling and reduce the effectiveness of BCR kinase inhibitors. Therefore, simultaneous targeting of the IL4- and BCR signaling pathways by cerdulatinib, a novel dual Syk/JAK inhibitor currently in clinical trials (NCT01994382), may improve treatment responses in patients.Experimental Design: PBMCs from patients with CLL were treated in vitro with cerdulatinib alone or in combination with venetoclax. Cell death, chemokine, and cell signaling assay were performed and analyzed by flow cytometry, immunoblotting, q-PCR, and ELISA as indicated.Results: At concentrations achievable in patients, cerdulatinib inhibited BCR- and IL4-induced downstream signaling in CLL cells using multiple readouts and prevented anti-IgM- and nurse-like cell (NLC)-mediated CCL3/CCL4 production. Cerdulatinib induced apoptosis of CLL cells, in a time- and concentration-dependent manner, and particularly in IGHV-unmutated samples with greater BCR signaling capacity and response to IL4, or samples expressing higher levels of sIgM, CD49d+, or ZAP70+ Cerdulatinib overcame anti-IgM, IL4/CD40L, or NLC-mediated protection by preventing upregulation of MCL-1 and BCL-XL; however, BCL-2 expression was unaffected. Furthermore, in samples treated with IL4/CD40L, cerdulatinib synergized with venetoclax in vitro to induce greater apoptosis than either drug alone.Conclusions: Cerdulatinib is a promising therapeutic for the treatment of CLL either alone or in combination with venetoclax, with the potential to target critical survival pathways in this currently incurable disease. Clin Cancer Res; 23(9); 2313-24. ©2016 AACR.
Collapse
MESH Headings
- Adenine/analogs & derivatives
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Apoptosis/drug effects
- B-Lymphocytes/drug effects
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Flow Cytometry
- Gene Expression Regulation, Neoplastic/drug effects
- Humans
- Janus Kinase Inhibitors/administration & dosage
- Janus Kinases/antagonists & inhibitors
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukocytes, Mononuclear/drug effects
- Neoplasm Proteins/genetics
- Piperidines
- Proto-Oncogene Proteins c-bcr/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcr/genetics
- Pyrazoles/administration & dosage
- Pyrimidines/administration & dosage
- Receptors, Antigen, B-Cell/drug effects
- Signal Transduction/drug effects
- Sulfonamides/administration & dosage
- Sulfones/administration & dosage
- Syk Kinase/antagonists & inhibitors
- Tumor Microenvironment/drug effects
Collapse
Affiliation(s)
- Matthew D Blunt
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Stefan Koehrer
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel C Dobson
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Marta Larrayoz
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Sarah Wilmore
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Alice Hayman
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Jack Parnell
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Lindsay D Smith
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Andrew Davies
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Peter W M Johnson
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | | | - Anjali Pandey
- Portola Pharmaceuticals, South San Francisco, California
| | - Jonathan C Strefford
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Freda K Stevenson
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Graham Packham
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
| | - Francesco Forconi
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom
- Haematology Department at the University Hospital Southampton NHS Trust, Southampton, United Kingdom
| | - Greg P Coffey
- Portola Pharmaceuticals, South San Francisco, California
| | - Jan A Burger
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Andrew J Steele
- Cancer Sciences Unit (MP824), University of Southampton, Southampton, United Kingdom.
| |
Collapse
|
152
|
Itchaki G, Brown JR. Lenalidomide in the treatment of chronic lymphocytic leukemia. Expert Opin Investig Drugs 2017; 26:633-650. [PMID: 28388253 DOI: 10.1080/13543784.2017.1313230] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Lenalidomide is an immunomodulatory drug (IMiD) with a unique mode of action (MOA) that may vary across disease-type. It is currently approved in multiple myeloma (MM), myelodysplastic syndrome (MDS) and mantle cell lymphoma (MCL), yet is also clinically active in a host of lymphoproliferative diseases, including chronic lymphocytic leukemia (CLL). Due to its protean effects on the immune system, lenalidomide may be particularly appealing in CLL, which is distinct in its ability to evade immune recognition and cause immunosuppression. Areas covered: This review recaps the biological mechanisms of lenalidomide specific for CLL, and summarizes the clinical data in previously untreated and relapsed/refractory (R/R) CLL patients, with emphasis on toxicity. Moreover, lenalidomide treatment is put into the context of the highly effective targeted agents that are drastically changing the therapeutic approach in CLL. Expert opinion: Lenalidomide is a potent drug in CLL, both in first line and relapse. However, in comparison to other newly available agents, lenalidomide has slow onset of efficacy and notable toxicity profile that limits both its single agent use and combinations with chemotherapy. Future trials will hopefully direct our ability to harness lenalidomide MOA to best incorporate it in the rapidly evolving landscape of CLL treatment.
Collapse
Affiliation(s)
- Gilad Itchaki
- a Department of Medical Oncology , Dana Farber Cancer Institute , Boston , MA , USA
| | - Jennifer R Brown
- a Department of Medical Oncology , Dana Farber Cancer Institute , Boston , MA , USA
| |
Collapse
|
153
|
Molica S. Targeted therapy in the treatment of chronic lymphocytic leukemia: facts, shortcomings and hopes for the future. Expert Rev Hematol 2017; 10:425-432. [DOI: 10.1080/17474086.2017.1313108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Stefano Molica
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| |
Collapse
|
154
|
Advances in the treatment of relapsed/refractory chronic lymphocytic leukemia. Ann Hematol 2017; 96:1185-1196. [PMID: 28389687 PMCID: PMC5486803 DOI: 10.1007/s00277-017-2982-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/21/2017] [Indexed: 11/25/2022]
Abstract
Treatment of chronic lymphocytic leukemia (CLL) has advanced with the introduction of chemoimmunotherapy (CIT) agents that have improved the outcomes of frontline therapy. However, most treated patients will relapse and require subsequent therapy. This review focuses on recent advances in the treatment of relapsed or refractory CLL. Until recently, treatment options for relapsed CLL were of limited efficacy. Retreatment with fludarabine, cyclophosphamide, and rituximab (FCR) was recommended for patients with a durable response to first-line FCR, although acquired genetic aberrations, impaired marrow reserve, and comorbidities often made this suboptimal therapy for many patients. New options include two agents targeting B cell receptor (BCR) signaling pathways (ibrutinib and idelalisib) and a B cell lymphoma-2 (BCL-2) inhibitor (venetoclax). Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potentially curative option for younger patients with a suitable donor.
Collapse
|
155
|
Smith SM, Pitcher BN, Jung SH, Bartlett NL, Wagner-Johnston N, Park SI, Richards KL, Cashen AF, Jaslowski A, Smith SE, Cheson BD, Hsi E, Leonard JP. Safety and tolerability of idelalisib, lenalidomide, and rituximab in relapsed and refractory lymphoma: the Alliance for Clinical Trials in Oncology A051201 and A051202 phase 1 trials. LANCET HAEMATOLOGY 2017; 4:e176-e182. [PMID: 28314699 DOI: 10.1016/s2352-3026(17)30028-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND A new generation of biological and targeted agents might potentially replace traditional cytotoxic agents in lymphoma. Lenalidomide plus rituximab was felt to be a safe and promising backbone based on available data. Idelalisib is an oral phosphatidylinositol 3-kinase delta (PI3Kδ) inhibitor that has promising activity as a monotherapy in refractory indolent lymphomas. The primary objective of these two trials was to determine the maximum tolerated dose of lenalidomide in combination with rituximab and idelalisib in relapsed follicular and mantle cell lymphoma. METHODS A051201 (mantle cell lymphoma) and A051202 (follicular lymphoma) were phase 1 trials. Patients with histologically documented relapsed mantle cell lymphoma who had not received previous lenalidomide or idelalisib (A051201) were started with oral lenalidomide 15 mg on days 1-21 in a 28 day cycle, oral idelalisib 150 mg twice a day with continuous 28-day cycles, and intravenous rituximab 375 mg/m2 weekly during cycle 1. Patients with histologically documented relapsed follicular lymphoma and time to progression 6 months or longer from last rituximab-containing regimen (A051202) were started with oral lenalidomide 10 mg on days 1-21 every 28 days and oral idelalisib 150 mg twice a day with continuous 28-day cycles, and intravenous rituximab 375 mg/m2 on cycle 1, day 8, day 15, day 22, and cycle 2, day 1. The primary endpoints of the studies were safety and tolerability of combining idelalisib with lenalidomide and rituximab in patients with relapsed mantle cell lymphoma (A051201) and relapsed follicular lymphoma (A051202). All analyses were by intention to treat. The trials were registered at ClinicalTrials.gov, number NCT01838434 (A051201) and number NCT01644799 (A051202). FINDINGS Between July 9, 2013, and Sept 30, 2014, 11 patients (three with mantle cell lymphoma and eight with follicular lymphoma) were enrolled. Among the first eight patients, four experienced unexpected dose-limiting toxicities: grade 4 sepsis syndrome, grade 4 hypotension with grade 3 rash and fevers, grade 4 aspartate aminotransferase (AST) or alanine aminotransferase (ALT) elevation with fevers, and grade 3 pulmonary infection with grade 3 maculopapular rash. Symptom onset was 9-20 days after treatment initiation, coinciding with rituximab infusions. Both studies were amended to remove rituximab, but two of three additional patients had grade 3 rashes and one had grade 3 AST elevation. Both trials were permanently closed. The most common grade 3-4 adverse events were ALT elevation (two [67%] of three) and rash (two [67%] of three) for patients with mantle cell lymphoma and neutropenia (five [63%] of eight) and rash (four [50%] of eight) for patients with follicular lymphoma. The primary endpoint of safety and tolerability was not met. INTERPRETATION The combination of idelalisib, lenalidomide, and rituximab in these trials is excessively toxic, and these trials serve as cautionary notes as new combinations are proposed. Off-target effects, drug-drug interactions, and emerging toxicities should be carefully assessed when investigating biological agents in combination and should never be done outside of a clinical trial setting. FUNDING National Cancer Institute of the National Institutes of Health.
Collapse
Affiliation(s)
| | | | - Sin-Ho Jung
- Alliance Statistics and Data Center, Duke University, Durham, NC, USA
| | | | | | | | | | - Amanda F Cashen
- Washington University-Siteman Cancer Center, St Louis, MO, USA
| | | | | | - Bruce D Cheson
- MedStar Georgetown University Hospital, Washington, DC, USA
| | - Eric Hsi
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John P Leonard
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
156
|
Balakrishnan K, Bojja K, Decker W, Keating MJ. Hide and Seek: The Game Between Chronic Lymphocytic Leukaemia Cells and B Cell Receptor Signalling Inhibitors. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The emergence of B cell receptor (BCR) kinase inhibitors has recently changed the treatment landscape in chronic lymphocytic leukaemia (CLL). The inhibitors that selectively target potential kinases downstream from BCR (particularly Bruton’s tyrosine kinase [BTK] and phosphoinositide 3-kinase [PI3K]) have replaced conventional chemotherapy for high-risk CLL. Ibrutinib and idelalisib are the respective first-in-class BTK and PI3K-δ inhibitors that are US Food and Drug Administration (FDA) approved for CLL treatment, with promising second-generation molecules under development. Differing from idelalisib, duvelisib (IPI-145) inhibits both delta and gamma isoforms of PI3K. Kinase inhibitors have gained popularity in the clinic primarily due to their ability to induce remissions in the vast majority of patients, even in patients with high-risk disease features, without causing haematotoxicity. In particular, they interfere with the homing capabilities of CLL cells residing in their respective microenvironments and cause lymphocytosis via redistribution of tissue-resident CLL cells into the peripheral blood. Thereby, BCR inhibitors can seek out and target hiding CLL cells in the lymph node and marrow niches. In this review, we discuss laboratory and clinical aspects of the BCR inhibitors that have recently advanced the treatment of B cell malignancies, with a particular emphasis on CLL. Despite the excitement about this new class of compounds targeting BCR signalling, single agent therapy with kinase inhibitors has limitations, requiring continuous kinase suppression to maintain remissions, which generally are partial remissions, indicating that combination strategies will become important for moving the field forward.
Collapse
Affiliation(s)
- Kumudha Balakrishnan
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Krishna Bojja
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Michael J. Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
157
|
Vitale C, Griggio V, Todaro M, Salvetti C, Boccadoro M, Coscia M. Magic pills: new oral drugs to treat chronic lymphocytic leukemia. Expert Opin Pharmacother 2017; 18:411-425. [DOI: 10.1080/14656566.2017.1293655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Candida Vitale
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Valentina Griggio
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Maria Todaro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Chiara Salvetti
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Mario Boccadoro
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Marta Coscia
- Division of Hematology, University of Torino, AOU Città della Salute e della Scienza di Torino, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| |
Collapse
|
158
|
Goldfinger LE, Michael JV. Regulation of Ras signaling and function by plasma membrane microdomains. Biosci Trends 2017; 11:23-40. [PMID: 28179601 DOI: 10.5582/bst.2016.01220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Together H-, N- and KRAS mutations are major contributors to ~30% of all human cancers. Thus, Ras inhibition remains an important anti-cancer strategy. The molecular mechanisms of isotypic Ras oncogenesis are still not completely understood. Monopharmacological therapeutics have not been successful in the clinic. These disappointing outcomes have led to attempts to target elements downstream of Ras, mainly targeting either the Phosphatidylinositol 3-Kinase (PI3K) or Mitogen-Activated Protein Kinase (MAPK) pathways. While several such approaches are moderately effective, recent efforts have focused on preclinical evaluation of combination therapies to improve efficacies. This review will detail current understanding of the contributions of plasma membrane microdomain targeting of Ras to mitogenic and tumorigenic signaling and tumor progression. Moreover, this review will outline novel approaches to target Ras in cancers, including targeting schemes for new drug development, as well as putative re-purposing of drugs in current use to take advantage of blunting Ras signaling by interfering with Ras plasma membrane microdomain targeting and retention.
Collapse
Affiliation(s)
- Lawrence E Goldfinger
- Department of Anatomy & Cell Biology and The Sol Sherry Thrombosis Research Center, Lewis Katz School of Medicine at Temple University, and Cancer Biology Program, Fox Chase Cancer Center
| | | |
Collapse
|
159
|
Brown JR, Hallek MJ, Pagel JM. Chemoimmunotherapy Versus Targeted Treatment in Chronic Lymphocytic Leukemia: When, How Long, How Much, and in Which Combination? Am Soc Clin Oncol Educ Book 2017; 35:e387-98. [PMID: 27249745 DOI: 10.1200/edbk_159018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
During the past 5 years, rapid therapeutic advances have changed the landscape of chronic lymphocytic leukemia (CLL) therapy. This disease has traditionally been treated using cytotoxic chemotherapy regimens in combination with anti-CD20 antibody treatment, and recent long-term follow-up data from multiple centers suggest that fit patients with CLL with favorable disease features-particularly mutated immunoglobulin heavy chain variable region (IGHV) genes-derive very long-term benefit from the most potent of these regimens, namely the fludarabine, cyclophosphamide, and rituximab (FCR) regimen. The advent of oral targeted therapies, particularly ibrutinib and idelalisib, has provided generally well-tolerated and highly effective additional options that have come into widespread use in the relapsed setting. Additional agents are advancing in clinical development, with the BCL-2 inhibitor venetoclax likely to be approved by the U.S. Food and Drug Administration (FDA) in 2016. With the development of these novel therapies for patients with relapsed CLL, many unanswered questions remain, including the optimal sequence (first vs. second line), duration, discontinuation, and combination of these agents. In addition, recent publications show the emergence of a pattern of treatment resistance in certain subgroups of patients with del(17p) and complex karyotype that needs further study and improvement. Because the field of CLL management has become much more complex, we focus here on understanding the recent data and discuss many of the questions and controversies important for how we approach patients with CLL.
Collapse
Affiliation(s)
- Jennifer R Brown
- From the Dana-Farber Cancer Institute, Boston, MA; University Hospital of Cologne, Cologne, Germany; Swedish Cancer Institute, Seattle, WA
| | - Michael J Hallek
- From the Dana-Farber Cancer Institute, Boston, MA; University Hospital of Cologne, Cologne, Germany; Swedish Cancer Institute, Seattle, WA
| | - John M Pagel
- From the Dana-Farber Cancer Institute, Boston, MA; University Hospital of Cologne, Cologne, Germany; Swedish Cancer Institute, Seattle, WA
| |
Collapse
|
160
|
Idelalisib-induced colitis and skin eruption mimicking graft-versus-host disease. Clin J Gastroenterol 2016; 10:142-146. [PMID: 28025783 DOI: 10.1007/s12328-016-0707-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/09/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Idelalisib is a selective inhibitor of the delta isoform of phosphatidylinositol 3-kinase which was approved by the United States Federal Drug Administration in 2014 for the treatment of relapsed chronic lymphocytic leukemia and indolent non-Hodgkin lymphoma. Drug-induced injury of the gastrointestinal tract is a relatively frequent but usually under-recognized disease entity. CASE PRESENTATION We report the case of a 56-year-old male with a history of relapsed follicular lymphoma status post allogenic bone marrow transplant who developed severe diarrhea with a skin eruption mimicking graft-versus-host disease (GVHD) 6 months after starting idelalisib. He underwent a colonoscopy demonstrating a grossly normal-appearing colon and terminal ileum. Biopsies taken during the procedure revealed mild active ileitis, colitis, and proctitis with frequent epithelial apoptosis, and focal intra-epithelial lymphocytosis. Skin biopsies revealed sub-acute spongiotic dermatitis suggestive of either contact dermatitis or an eczematous drug reaction. Symptoms were attributed to idelalisib given their resolution with withdrawal of the drug in conjunction with the skin and colonic biopsies. CONCLUSION High clinical suspicion and awareness of the histological features of idelalisib-associated colitis is important to distinguish it from potential mimickers such as GVHD and infectious colitis.
Collapse
|
161
|
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.
Collapse
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
| |
Collapse
|
162
|
Korycka-Wołowiec A, Wołowiec D, Robak T. The safety profile of monoclonal antibodies for chronic lymphocytic leukemia. Expert Opin Drug Saf 2016; 16:185-201. [PMID: 27880061 DOI: 10.1080/14740338.2017.1264387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Monoclonal antibodies (MoAbs), non-chemotherapeutic agents targeting the antigens present on chronic lymphocytic leukemia (CLL) lymphocytes, are being implemented increasingly more often as treatment options. Areas covered: This article reviews the similarities and differences in the structure, mechanism of action, efficacy and safety profile of commercially-available MoAbs and prevents new agents potentially useful for CLL treatment. Publications in English before June 2016 were surveyed on the MEDLINE database for articles. Proceedings of the American Society of Hematology held during the last five years were also included. Expert opinion: MoAbs, especially those targeting CD20, are highly effective biological options for first-line and salvage treatment of CLL, particularly in chemoimmunotherapy, and possibly also as maintenance therapy. Treatment with MoAbs is associated with reduced risk of such adverse events as cytopenias, infections and secondary neoplasias and is generally well tolerated. Depending on antibody type, the most common adverse events are usually transient and limited to grade 1 and 2 infusion-related reactions. In addition to commercially available MoAbs, several other antibodies exist which are targeted against different antigens studied in the clinical trials.
Collapse
Affiliation(s)
| | - Dariusz Wołowiec
- b Department of Hematology , Medical University of Wroclaw , Wroclaw , Poland
| | - Tadeusz Robak
- a Department of Hematology Medical , University of Lodz , Lodz , Poland
| |
Collapse
|
163
|
Lamanna N, O’Brien S. Novel agents in chronic lymphocytic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:137-145. [PMID: 27913472 PMCID: PMC6142499 DOI: 10.1182/asheducation-2016.1.137] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The advent of novel small-molecule inhibitors has transformed the treatment approaches for patients with chronic lymphocytic leukemia (CLL). These therapies are becoming increasingly used in patients with relapsed disease, patients with 17p deletion, and, as of recently, also in the frontline setting for previously untreated patients with CLL. Moreover, many of these are oral therapies that are significantly less myelosuppressive than chemoimmunotherapy. However, these agents have their own set of unique toxicities with which providers must gain familiarity. There is also ongoing development of second-generation agents which have the promise of less toxicity than the US Food and Drug Administration (FDA)-approved compounds. In addition, immunotherapy and the role of the microenvironment are becoming increasingly important and have therapeutic implications in the treatment of patients with CLL. Ultimately, investigators need to evaluate how to position these and other new exciting therapies and decide on the ultimate role for chemoimmunotherapy in modern times.
Collapse
MESH Headings
- Antineoplastic Agents/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 17/genetics
- Chromosomes, Human, Pair 17/immunology
- Drug Approval
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Smith-Magenis Syndrome/genetics
- Smith-Magenis Syndrome/immunology
- Smith-Magenis Syndrome/therapy
- Tumor Microenvironment/immunology
- United States
- United States Food and Drug Administration
Collapse
Affiliation(s)
- Nicole Lamanna
- Leukemia Service, Chronic Lymphocytic Leukemia Program, Hematologic Malignancies Section, Herbert Irving Comprehensive Cancer Center, New York–Presbyterian/Columbia University Medical Center, New York, NY; and
| | - Susan O’Brien
- Chao Family Comprehensive Cancer Center, Sue and Ralph Stern Center for Clinical Trials & Research, Division of Hematology/Oncology, Department of Medicine, University of California, Irvine, Orange, CA
| |
Collapse
|
164
|
Barrientos JC. Sequencing of chronic lymphocytic leukemia therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:128-136. [PMID: 27913471 PMCID: PMC6142523 DOI: 10.1182/asheducation-2016.1.128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
It is an unprecedented time for the treatment of patients with chronic lymphocytic leukemia (CLL) with the recent approval of several targeted agents for use in frontline, relapsed, refractory, and high-risk disease. Traditionally, frontline management of CLL has been a combination of chemotherapy (fludarabine, cyclophosphamide, bendamustine, or chlorambucil) with an anti-CD20 monoclonal antibody (rituximab, ofatumumab, obinutuzumab). The current landscape is rapidly evolving with the advent of therapies that demonstrate selective inhibition of important pathways necessary for CLL proliferation and survival. Despite considerable progress, much is still unknown and optimal treatment selection and sequence is still debatable. None of the new agents have been compared against each other and the impact of adding an additional agent to monotherapy is not yet fully elucidated. In routine clinical practice, the choice of therapy is based on nonrandomized comparisons, presence of comorbidities, and toxicity considerations. These recently approved drugs (ibrutinib, idelalisib, and venetoclax) are reporting excellent outcomes, including patients with high-risk disease such as 17p deletion (17p-) or TP53 mutations (TP53mut). Ibrutinib and venetoclax have been approved for use in 17p- patients (frontline and relapsed, respectively). Ibrutinib is currently moving into the frontline space given recent regulatory approvals. This review will summarize and interpret the limited therapeutic sequencing data available, highlighting the need for additional studies to optimize combination strategies and treatments after failure or discontinuation of these novel agents.
Collapse
MESH Headings
- Alanine/analogs & derivatives
- Alanine/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride/therapeutic use
- Cell Proliferation/drug effects
- Cell Proliferation/genetics
- Chlorambucil/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 17/genetics
- Cyclophosphamide/therapeutic use
- DNA Mutational Analysis/methods
- Disease-Free Survival
- High-Throughput Nucleotide Sequencing
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Rituximab/therapeutic use
- Smith-Magenis Syndrome/drug therapy
- Smith-Magenis Syndrome/genetics
- Smith-Magenis Syndrome/mortality
- Tumor Suppressor Protein p53/genetics
Collapse
Affiliation(s)
- Jacqueline C Barrientos
- CLL Research and Treatment Program, Department of Internal Medicine, Hofstra Northwell School of Medicine, New Hyde Park, NY
| |
Collapse
|
165
|
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.
Collapse
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
Collapse
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
| |
Collapse
|
166
|
|
167
|
Mauro FR, Salaroli A, Caputo MD, Colafigli G, Petrucci L, Campanelli M, Ferretti A, Guarini AR, Foà R. Management of elderly and unfit patients with chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:1165-1175. [DOI: 10.1080/17474086.2016.1254544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
168
|
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]
|
169
|
Li YH, Wang PP, Li XX, Yu CY, Yang H, Zhou J, Xue WW, Tan J, Zhu F. The Human Kinome Targeted by FDA Approved Multi-Target Drugs and Combination Products: A Comparative Study from the Drug-Target Interaction Network Perspective. PLoS One 2016; 11:e0165737. [PMID: 27828998 PMCID: PMC5102354 DOI: 10.1371/journal.pone.0165737] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/17/2016] [Indexed: 11/18/2022] Open
Abstract
The human kinome is one of the most productive classes of drug target, and there is emerging necessity for treating complex diseases by means of polypharmacology (multi-target drugs and combination products). However, the advantages of the multi-target drugs and the combination products are still under debate. A comparative analysis between FDA approved multi-target drugs and combination products, targeting the human kinome, was conducted by mapping targets onto the phylogenetic tree of the human kinome. The approach of network medicine illustrating the drug-target interactions was applied to identify popular targets of multi-target drugs and combination products. As identified, the multi-target drugs tended to inhibit target pairs in the human kinome, especially the receptor tyrosine kinase family, while the combination products were able to against targets of distant homology relationship. This finding asked for choosing the combination products as a better solution for designing drugs aiming at targets of distant homology relationship. Moreover, sub-networks of drug-target interactions in specific disease were generated, and mechanisms shared by multi-target drugs and combination products were identified. In conclusion, this study performed an analysis between approved multi-target drugs and combination products against the human kinome, which could assist the discovery of next generation polypharmacology.
Collapse
Affiliation(s)
- Ying Hong Li
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Pan Pan Wang
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Xiao Xu Li
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Chun Yan Yu
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Hong Yang
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Jin Zhou
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Wei Wei Xue
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
| | - Jun Tan
- Institute of Bioinformation, Chongqing University of Posts and Telecommunications, Chongqing, China
| | - Feng Zhu
- Innovative Drug Research and Bioinformatics Group, Innovative Drug Research Centre and School of Pharmaceutical Sciences, Chongqing University, Chongqing, China
- * E-mail:
| |
Collapse
|
170
|
Van Den Neste E. Chronic lymphocytic leukemia management in the elderly: let us not forget the patient - even on a busy day. Leuk Lymphoma 2016; 58:509-510. [PMID: 27820965 DOI: 10.1080/10428194.2016.1251595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Eric Van Den Neste
- a Hematology Department , Cliniques universitaires UCL Saint-Luc , Brussels , Belgium
| |
Collapse
|
171
|
Lucas CL, Chandra A, Nejentsev S, Condliffe AM, Okkenhaug K. PI3Kδ and primary immunodeficiencies. Nat Rev Immunol 2016; 16:702-714. [PMID: 27616589 PMCID: PMC5291318 DOI: 10.1038/nri.2016.93] [Citation(s) in RCA: 215] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Primary immunodeficiencies are inherited disorders of the immune system, often caused by the mutation of genes required for lymphocyte development and activation. Recently, several studies have identified gain-of-function mutations in the phosphoinositide 3-kinase (PI3K) genes PIK3CD (which encodes p110δ) and PIK3R1 (which encodes p85α) that cause a combined immunodeficiency syndrome, referred to as activated PI3Kδ syndrome (APDS; also known as p110δ-activating mutation causing senescent T cells, lymphadenopathy and immunodeficiency (PASLI)). Paradoxically, both loss-of-function and gain-of-function mutations that affect these genes lead to immunosuppression, albeit via different mechanisms. Here, we review the roles of PI3Kδ in adaptive immunity, describe the clinical manifestations and mechanisms of disease in APDS and highlight new insights into PI3Kδ gleaned from these patients, as well as implications of these findings for clinical therapy.
Collapse
Affiliation(s)
- Carrie L Lucas
- Molecular Development of the Immune System Section, Laboratory of Immunology, and Clinical Genomics Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
- Immunobiology Department, Yale University School of Medicine, New Haven, Connecticut 06511, USA
| | - Anita Chandra
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Cambridge CB22 3AT, UK
- Department of Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Sergey Nejentsev
- Department of Medicine, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Alison M Condliffe
- Department of Infection, Immunity &Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK
| | - Klaus Okkenhaug
- Laboratory of Lymphocyte Signalling and Development, Babraham Institute, Cambridge CB22 3AT, UK
| |
Collapse
|
172
|
Städler N, Shang A, Bosch F, Briggs A, Goede V, Berthier A, Renaudin C, Leblond V. A Systematic Review and Network Meta-Analysis to Evaluate the Comparative Efficacy of Interventions for Unfit Patients with Chronic Lymphocytic Leukemia. Adv Ther 2016; 33:1814-1830. [PMID: 27535291 PMCID: PMC5055565 DOI: 10.1007/s12325-016-0398-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Rituximab plus fludarabine and cyclophosphamide (RFC) is the standard of care for fit patients with untreated chronic lymphocytic leukemia (CLL); however, its use is limited in 'unfit' (co-morbid and/or full-dose F-ineligible) patients due to its toxicity profile. We conducted a systematic review and Bayesian network meta-analysis (NMA) to determine the relative efficacy of commercially available interventions for the first-line treatment of unfit CLL patients. METHODS For inclusion in the NMA, studies had to be linked via common treatment comparators, report progression-free survival (PFS), and/or overall survival (OS), and meet at least one of the five inclusion criteria: median cumulative illness score >6, median creatinine clearance ≤70 mL/min, existing co-morbidities, median age ≥70 years, and no full-dose F in the comparator arm. A manual review, validated by external experts, of all studies that met at least one of these criteria was also performed to confirm that they evaluated first-line therapeutic options for unfit patients with CLL. RESULTS In unfit patients, the main NMA (five studies for PFS and four for OS) demonstrated clear preference in terms of PFS for obinutuzumab + chlorambucil (G-Clb) versus rituximab + chlorambucil (R-Clb), ofatumumab + chlorambucil (O-Clb), fludarabine and chlorambucil (median hazard ratios [HRs] 0.43, 0.33, 0.20, and 0.19, respectively), and a trend for better efficacy versus rituximab + bendamustine (R-Benda) and RFC-Lite (median HR 0.81 and 0.88, respectively). OS results were generally consistent with PFS data, (median HR 0.48, 0.53, and 0.81, respectively) for G-Clb versus Clb, O-Clb, and R-Clb 0.35 and 0.81 versus F and R-Benda, respectively); however, the OS findings were associated with higher uncertainty. Treatment ranking reflected improved PFS and OS with G-Clb over other treatment strategies (median rank of one for both endpoints). CONCLUSION G-Clb is likely to show superior efficacy to other treatment options selected in our NMA for unfit treatment-naïve patients with CLL. FUNDING F. Hoffmann-La Roche Ltd.
Collapse
Affiliation(s)
| | | | - Francesc Bosch
- Hematology Department, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Andrew Briggs
- Health Economics and Health Technology Assessment, University of Glasgow, Glasgow, UK
| | - Valentin Goede
- Department I of Internal Medicine, Center of Integrated Oncology Cologne-Bonn, University Hospital Cologne, Cologne, Germany
| | | | | | | |
Collapse
|
173
|
Okkenhaug K, Graupera M, Vanhaesebroeck B. Targeting PI3K in Cancer: Impact on Tumor Cells, Their Protective Stroma, Angiogenesis, and Immunotherapy. Cancer Discov 2016; 6:1090-1105. [PMID: 27655435 PMCID: PMC5293166 DOI: 10.1158/2159-8290.cd-16-0716] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 08/02/2016] [Indexed: 12/28/2022]
Abstract
The PI3K pathway is hyperactivated in most cancers, yet the capacity of PI3K inhibitors to induce tumor cell death is limited. The efficacy of PI3K inhibition can also derive from interference with the cancer cells' ability to respond to stromal signals, as illustrated by the approved PI3Kδ inhibitor idelalisib in B-cell malignancies. Inhibition of the leukocyte-enriched PI3Kδ or PI3Kγ may unleash antitumor T-cell responses by inhibiting regulatory T cells and immune-suppressive myeloid cells. Moreover, tumor angiogenesis may be targeted by PI3K inhibitors to enhance cancer therapy. Future work should therefore also explore the effects of PI3K inhibitors on the tumor stroma, in addition to their cancer cell-intrinsic impact. SIGNIFICANCE The PI3K pathway extends beyond the direct regulation of cancer cell proliferation and survival. In B-cell malignancies, targeting PI3K purges the tumor cells from their protective microenvironment. Moreover, we propose that PI3K isoform-selective inhibitors may be exploited in the context of cancer immunotherapy and by targeting angiogenesis to improve drug and immune cell delivery. Cancer Discov; 6(10); 1090-105. ©2016 AACR.
Collapse
Affiliation(s)
- Klaus Okkenhaug
- Laboratory of Lymphocyte Signalling and Development, The Babraham Institute, Babraham Research Campus, Cambridge, United Kingdom.
| | - Mariona Graupera
- Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | | |
Collapse
|
174
|
Sánchez-Ramón S, Dhalla F, Chapel H. Challenges in the Role of Gammaglobulin Replacement Therapy and Vaccination Strategies for Hematological Malignancy. Front Immunol 2016; 7:317. [PMID: 27597852 PMCID: PMC4993076 DOI: 10.3389/fimmu.2016.00317] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/05/2016] [Indexed: 12/13/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) are prone to present with antibody production deficits associated with recurrent or severe bacterial infections that might benefit from human immunoglobulin (Ig) (IVIg/SCIg) replacement therapy. However, the original IVIg trial data were done before modern therapies were available, and the current indications do not take into account the shift in the immune situation of current treatment combinations and changes in the spectrum of infections. Besides, patients affected by other B cell malignancies present with similar immunodeficiency and manifestations while they are not covered by the current IVIg indications. A potential beneficial strategy could be to vaccinate patients at monoclonal B lymphocytosis and monoclonal gammopathy of undetermined significance stages (for CLL and MM, respectively) or at B-cell malignancy diagnosis, when better antibody responses are attained. We have to re-emphasize the need for assessing and monitoring specific antibody responses; these are warranted to select adequately those patients for whom early intervention with prophylactic anti-infective therapy and/or IVIg is preferred. This review provides an overview of the current scenario, with a focus on prevention of infection in patients with hematological malignancies and the role of Ig replacement therapy.
Collapse
Affiliation(s)
- Silvia Sánchez-Ramón
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain; Department of Microbiology I, Complutense University School of Medicine, Madrid, Spain
| | - Fatima Dhalla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Clinical Immunology, John Radcliffe Hospital, Headington, Oxford, UK
| | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Clinical Immunology, John Radcliffe Hospital, Headington, Oxford, UK
| |
Collapse
|
175
|
Rodrigues CA, Gonçalves MV, Ikoma MRV, Lorand-Metze I, Pereira AD, Farias DLCD, Chauffaille MDLLF, Schaffel R, Ribeiro EFO, Rocha TSD, Buccheri V, Vasconcelos Y, Figueiredo VLDP, Chiattone CS, Yamamoto M. Diagnosis and treatment of chronic lymphocytic leukemia: recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia. Rev Bras Hematol Hemoter 2016; 38:346-357. [PMID: 27863764 PMCID: PMC5119662 DOI: 10.1016/j.bjhh.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic lymphocytic leukemia is characterized by clonal proliferation and progressive accumulation of B-cell lymphocytes that typically express CD19+, CD5+ and CD23+. The lymphocytes usually infiltrate the bone marrow, peripheral blood, lymph nodes, and spleen. The diagnosis is established by immunophenotyping circulating B-lymphocytes, and prognosis is defined by two staging systems (Rai and Binet) established by physical examination and blood counts, as well as by several biological and genetic markers. In this update, we present the recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia for the diagnosis and treatment of chronic lymphocytic leukemia. The following recommendations are based on an extensive literature review with the aim of contributing to more uniform patient care in Brazil and possibly in other countries with a similar social–economic profile.
Collapse
Affiliation(s)
- Celso Arrais Rodrigues
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Hospital Sírio Libanês, São Paulo, SP, Brazil.
| | - Matheus Vescovi Gonçalves
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Fleury Medicina e Saúde, São Paulo, SP, Brazil
| | | | | | | | | | | | - Rony Schaffel
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | - Talita Silveira da Rocha
- A.C Camargo Cancer Center, São Paulo, SP, Brazil; Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Valeria Buccheri
- Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP, Brazil
| | - Yuri Vasconcelos
- Instituto Goiano de Oncologia e Hematologia (INGOH), Goiânia, GO, Brazil
| | | | - Carlos Sérgio Chiattone
- Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Hospital Samaritano, São Paulo, SP, Brazil
| | - Mihoko Yamamoto
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | |
Collapse
|
176
|
New treatment approaches in CLL: Challenges and opportunities in the elderly. J Geriatr Oncol 2016; 7:375-82. [PMID: 27491497 DOI: 10.1016/j.jgo.2016.07.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/15/2016] [Accepted: 07/18/2016] [Indexed: 11/21/2022]
Abstract
The majority of patients with chronic lymphocytic leukemia (CLL) are over 70years old. These patients vary in their vulnerability toward treatment efforts. Heterogeneity in fitness of older patients with CLL is mainly determined by individual differences in physiological aging and pathological conditions such as comorbidities and geriatric syndromes. Various options exist to treat older patients with CLL outside and inside clinical trials. Among these are new treatment approaches, including chemoimmunotherapy with engineered CD20 antibodies (e.g., obinutuzumab), single agent therapy with kinase inhibitors (e.g., ibrutinib, idelalisib), other targeted drug therapy (e.g., venetoclax, lenalidomide), and combinations of these novel compounds. Treatment recommendations for older patients take patient-related as well as disease-related risk factors into consideration. Emerging new treatment approaches in older patients offer novel opportunities, but also novel challenges which are discussed in this review.
Collapse
|
177
|
Ibrutinib inhibits CD20 upregulation on CLL B cells mediated by the CXCR4/SDF-1 axis. Blood 2016; 128:1609-13. [PMID: 27480113 DOI: 10.1182/blood-2016-04-709519] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/19/2016] [Indexed: 12/14/2022] Open
Abstract
Agents targeting B-cell receptor (BCR) signaling-associated kinases such as Bruton tyrosine kinase (BTK) or phosphatidylinositol 3-kinase can induce mobilization of neoplastic B cells from the lymphoid tissues into the blood, which makes them potentially ideal to combine with anti-CD20 monoclonal antibodies (such as rituximab, obinutuzumab, or ofatumumab) for treatment of B-cell lymphomas and chronic lymphocytic leukemia (CLL). Here we show that interactions between leukemia cells and stromal cells (HS-5) upregulate CD20 on CLL cells and that administering ibrutinib downmodulates CD20 (MS4A1) expression in vivo. We observed that CLL cells that have recently exited the lymph node microenvironment and moved into the peripheral blood (CXCR4(dim)CD5(bright) subpopulation) have higher cell surface levels of CD20 than the cells circulating in the bloodstream for a longer time (CXCR4(bright)CD5(dim) cells). We found that CD20 is directly upregulated by CXCR4 ligand stromal cell-derived factor 1 (SDF-1α, CXCL12) produced by stromal cells, and BTK-inhibitor ibrutinib and CXCR4-inhibitor plerixafor block SDF-1α-mediated CD20 upregulation. Ibrutinib also downmodulated Mcl1 levels in CLL cells in vivo and in coculture with stromal cells. Overall, our study provides a first detailed mechanistic explanation of CD20 expression regulation in the context of chemokine signaling and microenvironmental interactions, which may have important implications for microenvironment-targeting therapies.
Collapse
|
178
|
Montserrat E, Dreger P. Treatment of Chronic Lymphocytic Leukemia With del(17p)/TP53 Mutation: Allogeneic Hematopoietic Stem Cell Transplantation or BCR-Signaling Inhibitors? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16 Suppl:S74-81. [DOI: 10.1016/j.clml.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
|
179
|
|
180
|
Barrientos JC. Idelalisib for the treatment of chronic lymphocytic leukemia/small lymphocytic lymphoma. Future Oncol 2016; 12:2077-94. [PMID: 27324214 DOI: 10.2217/fon-2016-0003] [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] [Indexed: 12/28/2022] Open
Abstract
Idelalisib is a first-in-class selective oral PI3Kδ inhibitor for the treatment of patients with relapsed chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma, a predominantly elderly population with high comorbidity. The drug promotes apoptosis in primary CLL cells ex vivo, independent of common prognostic markers and inhibits CLL cell homing, migration and adhesion to cells in the microenvironment. Idelalisib has shown efficacy with acceptable safety as monotherapy and combination therapy in relapsed/refractory CLL. Idelalisib has clinical activity in patients with CLL with del(17p). The development of other novel B-cell-targeted agents provides the opportunity to evaluate additional idelalisib treatment combinations for their potential to further improve outcomes in CLL/small lymphocytic lymphoma.
Collapse
Affiliation(s)
- Jacqueline C Barrientos
- CLL Research & Treatment Program, Division of Hematology/Oncology, Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, 410 Lakeville Road, Suite 212, Lake Success, NY 11042, USA
| |
Collapse
|
181
|
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
| |
Collapse
|
182
|
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
| |
Collapse
|
183
|
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.
Collapse
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
| |
Collapse
|
184
|
Idelalisib given front-line for treatment of chronic lymphocytic leukemia causes frequent immune-mediated hepatotoxicity. Blood 2016; 128:195-203. [PMID: 27247136 DOI: 10.1182/blood-2016-03-707133] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/11/2016] [Indexed: 11/20/2022] Open
Abstract
Idelalisib is a small-molecule inhibitor of PI3Kδ with demonstrated efficacy for the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL). To evaluate idelalisib as front-line therapy, we enrolled 24 subjects in a phase 2 study consisting of 2 months of idelalisib monotherapy followed by 6 months of combination therapy with idelalisib and the anti-CD20 antibody ofatumumab. After a median follow-up period of 14.7 months, hepatotoxicity was found to be a frequent and often severe adverse event. A total of 19 subjects (79%) experienced either grade ≥1 ALT or AST elevation during the study, and 13 subjects (54%) experienced grade ≥3 transaminitis. The median time to development of transaminitis was 28 days, occurring before ofatumumab introduction. Younger age and mutated immunoglobulin heavy chain status were significant risk factors for the development of hepatotoxicity. Multiple lines of evidence suggest that this hepatotoxicity was immune mediated. A lymphocytic infiltrate was seen on liver biopsy specimens taken from 2 subjects with transaminitis, and levels of the proinflammatory cytokines CCL-3 and CCL-4 were higher in subjects experiencing hepatotoxicity. All cases of transaminitis resolved either by holding the drug, initiating immunosuppressants, or both, and rates of recurrent toxicity were lower in patients taking steroids when idelalisib was reinitiated. A decrease in peripheral blood regulatory T cells was seen in patients experiencing toxicity on therapy, which is consistent with an immune-mediated mechanism. These results suggest that caution should be taken as drugs within this class are developed for CLL, particularly in younger patients who have not received prior disease-specific therapy. This study was registered at www.clinicaltrials.gov as #NCT02135133.
Collapse
|
185
|
Speed bumps on the road to a chemotherapy-free world for lymphoma patients. Blood 2016; 128:325-30. [PMID: 27222479 DOI: 10.1182/blood-2016-04-709477] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/21/2016] [Indexed: 12/26/2022] Open
Abstract
With the increasing number of targeted agents for the treatment of patients with lymphoid malignancies comes the promise of safe and effective chemotherapy-free treatment strategies. A number of single agents, such as ibrutinib and idelalisib, have demonstrated impressive efficacy with a favorable toxicity profile. The observations that most responses are, however, partial and treatment duration is indefinite have stimulated interest in combinations of these agents with chemotherapy as well as with each other. Despite the promise of this approach, several recent trials of combinations of agents have been terminated as the result of life-threatening and fatal complications. Such outcomes have generated a cautionary note of the potential for unforeseen adverse effects that challenge drug development and mitigate against the empiric combination of such drugs outside of a clinical trial setting.
Collapse
|
186
|
Chemotherapy-sparing treatment strategies for follicular lymphoma: current options and future directions. Curr Opin Hematol 2016; 23:371-6. [PMID: 27213499 DOI: 10.1097/moh.0000000000000263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The accelerating development of targeted therapy offers the possibility of avoiding the many toxic side-effects of cytotoxic chemotherapy often experienced during treatment of patients with malignancies. As a currently incurable disease that typically follows an indolent course, follicular lymphoma is a disease for which chemotherapy-free treatment may offer substantial benefit. RECENT FINDINGS We review chemotherapy-free treatment regimens, including those targeting cell-surface proteins and intracellular signaling pathways currently in use for the treatment of follicular lymphoma, paying particular attention to the unique toxicity profiles of these agents. Additionally, the safety profiles and efficacy of selected novel-targeted therapies in earlier phase studies, including immunotherapeutics, will be explored. SUMMARY Novel-targeted therapies are rapidly changing the landscape of follicular lymphoma and decreasing reliance upon traditional chemotherapeutics. Although the toxicities of chemotherapy are well known to clinicians, the unique adverse events associated with novel agents may be less familiar, and requires attention to identification, management, and prophylaxis of toxicity associated with emerging chemotherapy-sparing treatments.
Collapse
|
187
|
Frustaci AM, Tedeschi A, Picardi P, Mazzucchelli M, Cairoli R, Montillo M. Ofatumumab plus chlorambucil as a first-line therapy in less fit patients with chronic lymphocytic leukemia: analysis of COMPLEMENT1 and other monoclonal antibodies association data. Ther Adv Hematol 2016; 7:222-30. [PMID: 27493712 DOI: 10.1177/2040620716648567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The management of patients with chronic lymphocytic leukemia (CLL) has radically improved over the last few years with the addition of anti-CD20 monoclonal antibodies (MoAbs) to chemotherapy. Chlorambucil has been considered for decades as a suitable therapeutic option for frail patients. Taking into account the advantage offered by the addition of MoAbs to chemotherapy, different studies up to now have explored the feasibility of chlorambucil-based chemoimmunotherapies in treatment-naïve CLL. COMPLEMENT1 is a prospective, randomized, open-label trial evaluating the efficacy and safety of ofatumumab added to chlorambucil, compared with chlorambucil in monotherapy, in the setting of untreated patients with CLL considered unsuitable for a fludarabine-based approach. Progression-free survival was significantly longer in the chemoimmunotherapy arm when compared with the single-agent chlorambucil (22.4 months versus 13.1 months). Response rate and quality were also improved in the combination arm. Furthermore, the addition of ofatumumab did not lead to an unmanageable toxicity. While the employment of anti-CD20 antibodies represents an advantage in the treatment of the CLL symptomatic population, at present different patient selection and treatment schedules do not allow a reliable comparison between chlorambucil-based regimens. The addition of ofatumumab to chlorambucil represents a further therapeutic gain in CLL. Longer follow up and direct comparison with other MoAbs are warranted to establish the preferred first-line treatment in elderly and unfit patients.
Collapse
Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | | | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| |
Collapse
|
188
|
Barrientos JC. Idelalisib for the treatment of indolent non-Hodgkin lymphoma: a review of its clinical potential. Onco Targets Ther 2016; 9:2945-53. [PMID: 27274288 PMCID: PMC4876096 DOI: 10.2147/ott.s102573] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Idelalisib is a first-in-class, oral, selective phosphatidylinositol 3-kinase δ inhibitor that offers a chemotherapy-free option for patients with relapsed or refractory (R/R) indolent non-Hodgkin lymphoma (iNHL). Clinical trials in iNHL have evaluated idelalisib as monotherapy and as combination therapy with rituximab, bendamustine, and rituximab + bendamustine. When administered to heavily pretreated patients with R/R iNHL, idelalisib monotherapy or combination therapy showed durable antitumor activity accompanied by sustained or improved quality-of-life outcomes. Idelalisib has an acceptable safety profile; however, serious or fatal diarrhea/colitis, hepatoxicity, pneumonitis, and intestinal perforation have occurred in treated patients. Selective inhibition of phosphatidylinositol 3-kinase δ with idelalisib is a valuable addition to available treatment options for patients with iNHL, many of whom do not respond to or cannot tolerate chemoimmunotherapy. Two Phase III, randomized, placebo-controlled trials of idelalisib as combination therapy with rituximab or bendamustine + rituximab and a Phase I trial of idelalisib in combination with the Bruton’s tyrosine kinase inhibitor ONO/GS-4059 in R/R B-cell malignancies are currently ongoing. A Phase III monotherapy trial in previously treated follicular lymphoma or small lymphocytic lymphoma is planned. The development of other kinase inhibitors for the treatment of iNHL raises the potential for new treatment combinations. Additional research is needed to determine optimal therapy (monotherapy vs combination regimens), treatment sequencing, and long-term management.
Collapse
Affiliation(s)
- Jacqueline C Barrientos
- CLL Research and Treatment Program, Division of Hematology/Oncology, Department of Medicine, Hofstra Northwell School of Medicine, Hofstra University, Lake Success, NY, USA
| |
Collapse
|
189
|
Thompson PA, Stingo F, Keating MJ, Ferrajoli A, Burger JA, Wierda WG, Kadia TM, O'Brien SM. Outcomes of patients with chronic lymphocytic leukemia treated with first-line idelalisib plus rituximab after cessation of treatment for toxicity. Cancer 2016; 122:2505-11. [PMID: 27182988 DOI: 10.1002/cncr.30069] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/18/2016] [Accepted: 03/29/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND More active therapies are needed for older and unfit patients with chronic lymphocytic leukemia (CLL) who are not eligible for chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab. The phosphyotidylinositol-3-kinase δ inhibitor idelalisib is effective in patients with treatment-naive and relapsed/refractory CLL as monotherapy and in combination with rituximab, but it can be associated with treatment-limiting adverse events, particularly diarrhea/colitis. The outcomes for patients who cease treatment for adverse events have not been previously described. METHODS The authors analyzed long-term follow-up data from 40 treatment-naïve patients aged ≥65 years who received treatment at The University of Texas MD Anderson Cancer Center on a phase 2 study of idelalisib plus rituximab for CLL. RESULTS In patients who permanently ceased treatment because of toxicity, the time to subsequent disease progression was analyzed according to baseline characteristics. Fifteen patients permanently ceased therapy (PCT) because of toxicity (PCTTOX ), most commonly diarrhea/colitis (n = 7), at a median of 11 months after commencing treatment. PCTTOX was associated with a higher risk of subsequent disease progression (hazard ratio, 6.61; 95% confidence interval, 1.77-16.15) relative to that observed in patients who remained on therapy. Ten patients subsequently progressed, and 7 required salvage therapy; 5 patients remained progression-free at a median of 23.3 months (range, 8.5-28.6 months). Patients who were positive for ζ-associated protein-70 had more rapid disease progression after treatment cessation (P = .048). There were no CLL-related deaths. CONCLUSIONS PCTTOX is the major determinant of PFS in patients who receive first-line idelalisib-based treatment. However, a subgroup of patients with favorable biologic characteristics has prolonged PFS, even after PCTTOX . The absence of CLL-related deaths indicates that salvage treatment is generally successful after PCTTOX . Cancer 2016;122:2505-11. © 2016 American Cancer Society.
Collapse
Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Francesco Stingo
- Department of Biostatistics, 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
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan A Burger
- Department of Leukemia, 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
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan M O'Brien
- The University of California Irvine Chao Family Comprehensive Cancer Center, Orange, California
| |
Collapse
|
190
|
Safdari Y, Ahmadzadeh V, Farajnia S. CD20-targeting in B-cell malignancies: novel prospects for antibodies and combination therapies. Invest New Drugs 2016; 34:497-512. [DOI: 10.1007/s10637-016-0349-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 03/22/2016] [Indexed: 12/13/2022]
|
191
|
Madanat YF, Smith MR, Almasan A, Hill BT. Idelalisib therapy of indolent B-cell malignancies: chronic lymphocytic leukemia and small lymphocytic or follicular lymphomas. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2016; 6:1-6. [PMID: 27375364 PMCID: PMC4929980 DOI: 10.2147/blctt.s73530] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Chronic lymphocytic leukemia, small lymphocytic lymphoma, and follicular lymphoma are indolent B-cell lymphoproliferative disorders that mainly affect an older population. Although the majority of patients in need of treatment derive significant benefit from conventional chemotherapeutic agents as well as monoclonal antibodies, less toxic and more effective treatments are needed. Novel agents that inhibit the B-cell receptor signaling pathway have shown promising outcomes in these disorders. Idelalisib is a potent selective oral inhibitor of phosphatidylinositol 3-kinase delta and has shown significant clinical activity in B-cell malignancies. In this review, we summarize the clinical trial data using idelalisib as monotherapy or in combination with rituximab for the treatment of relapsed/refractory disease. The adverse effect profile includes autoimmune disorders such as transaminitis, colitis, and pneumonitis. Given the efficacy and manageable toxicity profile of idelalisib, it is being increasingly incorporated into the management of indolent B-cell malignancies.
Collapse
Affiliation(s)
- Yazan F Madanat
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Mitchell R Smith
- Department of Hematology, Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alexandru Almasan
- Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian T Hill
- Department of Hematology, Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
192
|
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.
Collapse
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
| |
Collapse
|
193
|
Abstract
Recent investigations have provided an increasingly complete picture of the genetic landscape of chronic lymphocytic leukaemia (CLL). These analyses revealed that the CLL genome displays a high degree of heterogeneity between patients and within the same patient. In addition, they highlighted molecular mechanisms and functionally relevant biological programmes that may be important for the pathogenesis and therapeutic targeting of this disease. This Review focuses on recent insights into the understanding of CLL biology, with emphasis on the role of genetic lesions in the initiation and clinical progression of CLL. We also consider the translation of these findings into the development of risk-adapted and targeted therapeutic approaches.
Collapse
Affiliation(s)
- Giulia Fabbri
- Institute for Cancer Genetics, Columbia University, New York, New York 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York 10032, USA
| | - Riccardo Dalla-Favera
- Institute for Cancer Genetics, Columbia University, New York, New York 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York 10032, USA
- Department of Pathology and Cell Biology and New York, New York 10032, USA
- Departments of Genetics and Development and Microbiology and Immunology, Columbia University, New York, New York 10032, USA
| |
Collapse
|
194
|
BCR Signaling Inhibitors: an Overview of Toxicities Associated with Ibrutinib and Idelalisib in Patients with Chronic Lymphocytic Leukemia. Mediterr J Hematol Infect Dis 2016; 8:e2016011. [PMID: 26977270 PMCID: PMC4771137 DOI: 10.4084/mjhid.2016.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 01/25/2016] [Indexed: 12/24/2022] Open
Abstract
The B-cell receptor (BCR) signaling inhibitors ibrutinib and idelalisib are revolutionizing the treatment of chronic lymphocytic leukemia (CLL) and other B-cell malignancies. These oral agents, both alone and in combination with other drugs, have shown remarkable clinical activity in relapsed or refractory CLL across all risk groups, and have been approved by the Food and Drug Administration for this indication. Preliminary data suggest that an even greater benefit can be expected in treatment-naïve CLL patients. Both ibrutinib and idelalisib are well tolerated by most patients, including older, frailer individuals. Toxicities are usually mild and self-resolving. Clinicians must, however, be aware of a number of peculiar adverse events, the effects of which can be severe enough to limit the clinical use of these agents. In this review, we survey the salient aspects of the pharmacology and clinical experience with the use of BCR signaling inhibitors for the treatment of patients with CLL. We next focus on both the most common and the most clinically significant toxicities associated with these drugs.
Collapse
|
195
|
Abstract
INTRODUCTION B-cell Non-Hodgkin lymphomas (B-NHLs) include a number of disease subtypes, each defined by the tempo of disease progression and the identity of the cancerous cell. Idelalisib is a potent, selective inhibitor of the delta isoform of phosphatidylinositol-3-kinase (PI3K), a lipid kinase whose over-activity in B-NHL drives disease progression. Idelalisib has demonstrated activity in indolent B-NHL (iB-NHL) and is approved for use as monotherapy in patients with follicular lymphoma and small lymphocytic lymphoma and in combination with rituximab in patients with chronic lymphocytic leukemia. AREAS COVERED Herein we review the development and pharmacology of idelalisib, its safety and efficacy in clinical studies of iB-NHL, and its potential for inclusion in future applications in iB-NHL and in combination with other therapies. EXPERT OPINION Idelalisib adds to the growing arsenal of iB-NHL pharmacotherapeutics and to the progression of the field toward precision agents with good efficacy and reduced toxicities. Nevertheless, idelalisib carries important risks that require careful patient counseling and monitoring. The appropriate sequencing of idelalisib with other proven treatment options in addition to its potential for combination with established or novel drugs will be borne out in ongoing and planned investigations.
Collapse
Affiliation(s)
- Ajay Gopal
- University of Washington, Washington, United States
| | - Solomon Graf
- University of Washington, Washington, United States
- Fred Hutchinson Cancer Research Center, Seattle, United States
- Veterans Affairs Puget Sound Health Care System, Seattle, United States
| |
Collapse
|
196
|
Bhome R, Al Saihati H, Goh R, Bullock M, Primrose J, Thomas G, Sayan A, Mirnezami A. Translational aspects in targeting the stromal tumour microenvironment: from bench to bedside. NEW HORIZONS IN TRANSLATIONAL MEDICINE 2016; 3:9-21. [PMID: 27275004 PMCID: PMC4888939 DOI: 10.1016/j.nhtm.2016.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 03/07/2016] [Accepted: 03/24/2016] [Indexed: 02/07/2023]
Abstract
Solid tumours comprise, not only malignant cells but also a variety of stromal cells and extracellular matrix proteins. These components interact via an array of signalling pathways to create an adaptable network that may act to promote or suppress cancer progression. To date, the majority of anti-tumour chemotherapeutic agents have principally sought to target the cancer cell. Consequently, resistance develops because of clonal evolution, as a result of selection pressure during tumour expansion. The concept of activating or inhibiting other cell types within the tumour microenvironment is relatively novel and has the advantage of targeting cells which are genetically stable and less likely to develop resistance. This review outlines key players in the stromal tumour microenvironment and discusses potential targeting strategies that may offer therapeutic benefit.
Collapse
Affiliation(s)
- R. Bhome
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
- University Surgery, South Academic Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - H.A. Al Saihati
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - R.W. Goh
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
- School of Medicine, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - M.D. Bullock
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
- University Surgery, South Academic Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - J.N. Primrose
- University Surgery, South Academic Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - G.J. Thomas
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - A.E. Sayan
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - A.H. Mirnezami
- Cancer Sciences, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
- University Surgery, South Academic Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| |
Collapse
|
197
|
|