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Lee CH, Wu YY, Huang TC, Lin C, Zou YF, Cheng JC, Chen PH, Jhou HJ, Ho CL. Maintenance therapy for chronic lymphocytic leukaemia. Cochrane Database Syst Rev 2024; 1:CD013474. [PMID: 38174814 PMCID: PMC10765471 DOI: 10.1002/14651858.cd013474.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common lymphoproliferative disease in adults and currently remains incurable. As the progression-free period shortens after each successive treatment, strategies such as maintenance therapy are needed to improve the degree and duration of response to previous therapies. Monoclonal antibodies, immunomodulatory agents, and targeted therapies are among the available options for maintenance therapy. People with CLL who achieve remission after previous therapy may choose to undergo medical observation or maintenance therapy to deepen the response. Even though there is widespread use of therapeutic maintenance agents, the benefits and harms of these treatments are still uncertain. OBJECTIVES To assess the effects and safety of maintenance therapy, including anti-CD20 monoclonal antibody, immunomodulatory drug therapy, anti-CD52 monoclonal antibody, Bruton tyrosine kinase inhibitor, and B-cell lymphoma-2 tyrosine kinase inhibitor, for individuals with CLL. SEARCH METHODS We conducted a comprehensive literature search for randomised controlled trials (RCTs) with no language or publication status restrictions. We searched CENTRAL, MEDLINE, Embase, and three trials registers in January 2022 together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included RCTs with prospective identification of participants. We excluded cluster-randomised trials, cross-over trial designs, and non-randomised studies. We included studies comparing maintenance therapies with placebo/observation or head-to-head comparisons. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We assessed risk of bias in the included studies using Cochrane's RoB 1 tool for RCTs. We rated the certainty of evidence for the following outcomes using the GRADE approach: overall survival (OS), health-related quality of life (HRQoL), grade 3 and 4 adverse events (AEs), progression-free survival (PFS), treatment-related mortality (TRM), treatment discontinuation (TD), and all adverse events (AEs). MAIN RESULTS We identified 11 RCTs (2393 participants) that met the inclusion criteria, including seven trials comparing anti-CD20 monoclonal antibodies (mAbs) (rituximab or ofatumumab) with observation in 1679 participants; three trials comparing immunomodulatory drug (lenalidomide) with placebo/observation in 693 participants; and one trial comparing anti-CD 52 mAbs (alemtuzumab) with observation in 21 participants. No comparisons of novel small molecular inhibitors were found. The median age of participants was 54.1 to 71.7 years; 59.5% were males. The type of previous induction treatment, severity of disease, and baseline stage varied among the studies. Five trials included early-stage symptomatic patients, and three trials included advanced-stage patients (Rai stage III/IV or Binet stage B/C). Six trials reported a frequent occurrence of cytogenic aberrations at baseline (69.7% to 80.1%). The median follow-up duration was 12.4 to 73 months. The risk of selection bias in the included studies was unclear. We assessed overall risk of performance bias and detection bias as low risk for objective outcomes and high risk for subjective outcomes. Overall risk of attrition bias, reporting bias, and other bias was low. Anti-CD20 monoclonal antibodies (mAbs): rituximab or ofatumumab maintenance versus observation Anti-CD20 mAbs maintenance likely results in little to no difference in OS (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.73 to 1.20; 1152 participants; 3 studies; moderate-certainty evidence) and likely increases PFS significantly (HR 0.61, 95% CI 0.50 to 0.73; 1255 participants; 5 studies; moderate-certainty evidence) compared to observation alone. Anti-CD20 mAbs may result in: an increase in grade 3/4 AEs (rate ratio 1.34, 95% CI 1.06 to 1.71; 1284 participants; 5 studies; low-certainty evidence); little to no difference in TRM (risk ratio 0.82, 95% CI 0.39 to 1.71; 1189 participants; 4 studies; low-certainty evidence); a slight reduction to no difference in TD (risk ratio 0.93, 95% CI 0.72 to 1.20; 1321 participants; 6 studies; low-certainty evidence); and an increase in all AEs (rate ratio 1.23, 95% CI 1.03 to 1.47; 1321 participants; 6 studies; low-certainty evidence) compared to the observation group. One RCT reported that there may be no difference in HRQoL between the anti-CD20 mAbs (ofatumumab) maintenance and the observation group (mean difference -1.70, 95% CI -8.59 to 5.19; 480 participants; 1 study; low-certainty evidence). Immunomodulatory drug (IMiD): lenalidomide maintenance versus placebo/observation IMiD maintenance therapy likely results in little to no difference in OS (HR 0.91, 95% CI 0.61 to 1.35; 461 participants; 3 studies; moderate-certainty evidence) and likely results in a large increase in PFS (HR 0.37, 95% CI 0.19 to 0.73; 461 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. Regarding harms, IMiD maintenance therapy may result in an increase in grade 3/4 AEs (rate ratio 1.82, 95% CI 1.38 to 2.38; 400 participants; 2 studies; low-certainty evidence) and may result in a slight increase in TRM (risk ratio 1.22, 95% CI 0.35 to 4.29; 458 participants; 3 studies; low-certainty evidence) compared to placebo/observation. The evidence for the effect on TD compared to placebo is very uncertain (risk ratio 0.71, 95% CI 0.47 to 1.05; 400 participants; 2 studies; very low-certainty evidence). IMiD maintenance therapy probably increases all AEs slightly (rate ratio 1.41, 95% CI 1.28 to 1.54; 458 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. No studies assessed HRQoL. Anti-CD52 monoclonal antibodies (mAbs): alemtuzumab maintenance versus observation Maintenance with alemtuzumab may have little to no effect on PFS, but the evidence is very uncertain (HR 0.55, 95% CI 0.32 to 0.95; 21 participants; 1 study; very low-certainty evidence). We did not identify any study reporting the outcomes OS, HRQoL, grade 3/4 AEs, TRM, TD, or all AEs. AUTHORS' CONCLUSIONS There is currently moderate- to very low-certainty evidence available regarding the benefits and harms of maintenance therapy in people with CLL. Anti-CD20 mAbs maintenance improved PFS, but also increased grade 3/4 AEs and all AEs. IMiD maintenance had a large effect on PFS, but also increased grade 3/4 AEs. However, none of the above-mentioned maintenance interventions show differences in OS between the maintenance and control groups. The effects of alemtuzumab maintenance are uncertain, coupled with a warning for drug-related infectious toxicity. We found no studies evaluating other novel maintenance interventions, such as B-cell receptor inhibitors, B-cell leukaemia-2/lymphoma-2 inhibitors, or obinutuzumab.
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Affiliation(s)
- Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ying Wu
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chuan Huang
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Fen Zou
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ju-Chun Cheng
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Athni TS, Barmettler S. Hypogammaglobulinemia, late-onset neutropenia, and infections following rituximab. Ann Allergy Asthma Immunol 2023; 130:699-712. [PMID: 36706910 PMCID: PMC10247428 DOI: 10.1016/j.anai.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/23/2022] [Accepted: 01/16/2023] [Indexed: 01/26/2023]
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody that targets CD20-expressing B lymphocytes, has a well-defined efficacy and safety profile, and is broadly used to treat a wide array of diseases. In this review, we cover the mechanism of action of rituximab and focus on hypogammaglobulinemia and late-onset neutropenia-2 immune effects secondary to rituximab-and subsequent infection. We review risk factors and highlight key considerations for immunologic monitoring and clinical management of rituximab-induced secondary immune deficiencies. In patients treated with rituximab, monitoring for hypogammaglobulinemia and infections may help to identify the subset of patients at high risk for developing poor B cell reconstitution, subsequent infections, and adverse complications. These patients may benefit from early interventions such as vaccination, antibacterial prophylaxis, and immunoglobulin replacement therapy. Systematic evaluation of immunoglobulin levels and peripheral B cell counts by flow cytometry, both at baseline and periodically after therapy, is recommended for monitoring. In addition, in those patients with prolonged hypogammaglobulinemia and increased infections after rituximab use, immunologic evaluation for inborn errors of immunity may be warranted to further risk stratification, increase monitoring, and assist in therapeutic decision-making. As the immunologic effects of rituximab are further elucidated, personalized approaches to minimize the risk of adverse reactions while maximizing benefit will allow for improved care of patients with decreased morbidity and mortality.
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Affiliation(s)
| | - Sara Barmettler
- Allergy and Clinical Immunology Unit, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, Massachusetts.
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3
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Lee HR, Kim K, Lee SW, Song JH, Lee JH, Hwang SD. Effect of rituximab dose on induction therapy in ABO-incompatible living kidney transplantation: A network meta-analysis. Medicine (Baltimore) 2021; 100:e24853. [PMID: 33725841 PMCID: PMC7969271 DOI: 10.1097/md.0000000000024853] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Rituximab is an induction immunosuppressant essential for ABO-incompatible kidney transplantation (ABOi KT). However, studies on its dosing, which differs among countries and transplant centers, are lacking. Therefore, we retrospectively investigated the effectiveness of the induction dose of rituximab against patient mortality, graft failure, and adverse events. METHODS We included the studies referring to at least 2 of eligible induction doses (200 mg, 200-500 mg, or 500 mg) of rituximab during ABOi KT and relevant outcomes such as patient survival, graft failure, and bacterial and viral infections. We performed direct and indirect network meta-analyses using Bayesian models and ranked different rituximab doses using generation mixed treatment comparison. Publications were retrieved using CENTRAL, MEDLINE, EMBASE, and Science Citation Index Expanded databases from 1970 to February 2020 and analyzed. The GRADE of network meta-analysis approach specified 4 levels of certainty for a given result: high, moderate, low, and very low. RESULTS Among the 4256 patients from 21 trials, glomerular filtration rate, graft loss, antibody-mediated rejection, T-cell mediated rejection, fungal infection, bacterial infection, and CMV infection did not differ among ABOi groups treated with different rituximab doses. The effect on mortality was significantly higher in rituximab 200 to 500 mg, and rituximab 500 mg groups (odds ratios [OR] 3.5, 95% CrI: 1.3-9.8, and OR 3.0, 95% CrI 1.1-9.8), but not in rituximab 20 mg group (OR 0.45, 95% CrI 0.036-2.5). The incidence of BK virus was significantly lower in the rituximab 200-mg group than in the other groups. DISCUSSION In ABO-incompatible kidney transplantation, low-dose rituximab is more efficacious than higher doses and reduces serious infection risks. Additional randomized controlled trials might be needed to confirm these findings due to small sample size.
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Affiliation(s)
- Hee Ryong Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Kipyo Kim
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Ho Lee
- Division of Nephrology, Department of Internal Medicine, Leesin Hemodialysis and Intervention Clinic, Busan
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
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Lee CH, Wu YY, Huang TC, Lin C, Zou YF, Cheng JC, Ho CL. Maintenance therapy for chronic lymphocytic leukaemia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Cho-Hao Lee
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Yi-Ying Wu
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Tzu-Chuan Huang
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Chin Lin
- National Defense Medical Center; School of Public Health; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Yi-Fen Zou
- Tri-Service General Hospital, National Defense Medical Center; Department of Pharmacy; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Ju-Chun Cheng
- Tri-Service General Hospital, National Defense Medical Center; Department of Pharmacy; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Ching-Liang Ho
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
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García-Marco JA, Jiménez JL, Recasens V, Zarzoso MF, González-Barca E, De Marcos NS, Ramírez MJ, Parraga FJP, Yañez L, De La Serna Torroba J, Malo MDG, Ariznavarreta GD, Persona EP, Guinaldo MAR, De Paz Arias R, Llanos EB, Jarque I, Valle MDCF, Tatay AC, De Oteyza JP, Martin EMD, Fernández IP, Martinez RM, Costa MAA, Champ D, Suarez JG, Díaz MG, Ferrer S, Carbonell F, García-Vela JA. High prognostic value of measurable residual disease detection by flow cytometry in chronic lymphocytic leukemia patients treated with front-line fludarabine, cyclophosphamide, and rituximab, followed by three years of rituximab maintenance. Haematologica 2019; 104:2249-2257. [PMID: 30890600 PMCID: PMC6821631 DOI: 10.3324/haematol.2018.204891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 03/18/2019] [Indexed: 12/21/2022] Open
Abstract
It has been postulated that monitoring measurable residual disease (MRD) could be used as a surrogate marker of progression-free survival (PFS) in chronic lymphocytic leukemia (CLL) patients after treatment with immunochemotherapy regimens. In this study, we analyzed the outcome of 84 patients at 3 years of follow-up after first-line treatment with fludarabine, cyclophosphamide and rituximab (FCR) induction followed by 36 months of rituximab maintenance thearpy. MRD was assessed by a quantitative four-color flow cytometry panel with a sensitivity level of 10−4. Eighty out of 84 evaluable patients (95.2%) achieved at least a partial response or better at the end of induction. After clinical evaluation, 74 patients went into rituximab maintenance and the primary endpoint was assessed in the final analysis at 3 years of follow-up. Bone marrow (BM) MRD analysis was performed after the last planned induction course and every 6 months in cases with detectable residual disease during the 36 months of maintenance therapy. Thirty-seven patients (44%) did not have detectable residual disease in the BM prior to maintenance therapy. Interestingly, 29 patients with detectable residual disease in the BM after induction no longer had detectable disease in the BM following maintenance therapy. After a median followup of 6.30 years, the median overall survival (OS) and PFS had not been reached in patients with either undetectable or detectable residual disease in the BM, who had achieved a complete response at the time of starting maintenance therapy. Interestingly, univariate analysis showed that after rituximab maintenance OS was not affected by IGHV status (mutated vs. unmutated OS: 85.7% alive at 7.2 years vs. 79.6% alive at 7.3 years, respectively). As per protocol, 15 patients (17.8%), who achieved a complete response and undetectable peripheral blood and BM residual disease after four courses of induction, were allowed to stop fludarabine and cyclophosphamide and complete two additional courses of rituximab and continue with maintenance therapy for 18 cycles. Surprisingly, the outcome in this population was similar to that observed in patients who received the full six cycles of the induction regimen. These data show that, compared to historic controls, patients treated with FCR followed by rituximab maintenance have high-quality responses with fewer relapses and improved OS. The tolerability of this regime is favorable. Furthermore, attaining an early undetectable residual disease status could shorten the duration of chemoimmunotherapy, reducing toxicities and preventing long-term side effects. The analysis of BM MRD after fludarabine-based induction could be a powerful predictor of post-maintenance outcomes in patients with CLL undergoing rituximab maintenance and could be a valuable tool to identify patients at high risk of relapse, influencing further treatment strategies. This trial is registered with EudraCT n. 2007-002733-36 and ClinicalTrials.gov Identifier: NCT00545714.
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Affiliation(s)
| | | | | | | | - Eva González-Barca
- Hematology, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona
| | | | | | | | - Lucrecia Yañez
- Hospital Universitario Marqués de Valdecilla, Servicio de Hematologia, Santander
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marcos González Díaz
- Hematology, University Hospital of Salamanca-IBSAL, CIBERONC, USAL-CSIC, CIC-IBMCC, Salamanca
| | | | - Félix Carbonell
- Hematology, Consorcio Hospital General Universitario, Valencia
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Owen C, Gerrie AS, Banerji V, Assouline S, Chen C, Robinson KS, Lye E, Fraser G. Canadian evidence-based guideline for the first-line treatment of chronic lymphocytic leukemia. Curr Oncol 2018; 25:e461-e474. [PMID: 30464698 PMCID: PMC6209557 DOI: 10.3747/co.25.4092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In Canada, no unified national guideline exists for the front-line treatment of cll; provincial guidelines vary and are largely based on funding. A group of clinical experts from across Canada developed a national evidence-based treatment guideline to provide health care professionals with clear guidance on the first-line management of cll. Consensus recommendations based on available evidence are presented for the first-line treatment of cll.
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Affiliation(s)
- C Owen
- Division of Hematology and Hematological Malignancies, Foothills Medical Centre, Calgary, AB
| | - A S Gerrie
- Division of Medical Oncology, University of British Columbia and BC Cancer, Vancouver, BC
| | - V Banerji
- Department of Hematology and Medical Oncology, Cancer Care Manitoba, Winnipeg, MB
| | - S Assouline
- Department of Medical Oncology, McGill University and Jewish General Hospital, Montreal, QC
| | - C Chen
- Department of Medical Oncology, University of Toronto, and Princess Margaret Cancer Centre, Toronto, ON
| | - K S Robinson
- Division of Hematology, Dalhousie University, and qeii Health Sciences Centre, Halifax, NS
| | - E Lye
- Lymphoma Canada, Mississauga, ON
| | - G Fraser
- Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, ON
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Egle A, Pleyer L, Melchardt T, Hartmann TN, Greil R. Remission maintenance treatment options in chronic lymphocytic leukemia. Cancer Treat Rev 2018; 70:56-66. [PMID: 30121491 DOI: 10.1016/j.ctrv.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 02/07/2023]
Abstract
Chronic lymphocytic leukemia (CLL) treatment has come a long way in the last two decades, producing increases in tumor control to the point of generating sizeable numbers of patients with undetectable minimal residual disease and creating overall survival benefits in randomized comparisons. Most of this has been achieved by limited-term treatment approaches including chemotherapeutic and immune-therapeutic drugs. More recently, novel therapies targeting signaling pathways essential for the survival of the neoplastic clones have opened avenues that provide disease control in long-term treatment designs, mostly without producing deep remissions. In this disease, where current treatments are largely unable to effect a cure, prolonged therapy designs using maintenance approaches are explored and 5 randomized studies of maintenance have recently been published. This review shall summarize available results from a systematic literature review in a clinical context and outline basic biology principles that should be heeded in this regard.
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Affiliation(s)
- Alexander Egle
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Lisa Pleyer
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Thomas Melchardt
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Tanja Nicole Hartmann
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Richard Greil
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria.
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Tomuleasa C, Selicean C, Cismas S, Jurj A, Marian M, Dima D, Pasca S, Petrushev B, Moisoiu V, Micu WT, Vischer A, Arifeen K, Selicean S, Zdrenghea M, Bumbea H, Tanase A, Grewal R, Pop L, Aanei C, Berindan-Neagoe I. Minimal residual disease in chronic lymphocytic leukemia: A consensus paper that presents the clinical impact of the presently available laboratory approaches. Crit Rev Clin Lab Sci 2018; 55:329-345. [PMID: 29801428 DOI: 10.1080/10408363.2018.1463508] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a malignancy defined by the accumulation of mature lymphocytes in the lymphoid tissues, bone marrow, and blood. Therapy for CLL is guided according to the Rai and Binet staging systems. Nevertheless, state-of-the-art protocols in disease monitoring, diagnostics, and prognostics for CLL are based on the assessment of minimal residual disease (MRD). MRD is internationally considered to be the level of disease that can be detected by sensitive techniques and represents incomplete treatment and a probability of disease relapse. MRD detection has been continuously improved by the quick development of both flow cytometry and molecular biology technology, as well as by next-generation sequencing. Considering that MRD detection is moving more and more from research to clinical practice, where it can be an independent prognostic marker, in this paper, we present the methodologies by which MRD is evaluated, from translational research to clinical practice.
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Affiliation(s)
- Ciprian Tomuleasa
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania.,b Research Center for Functional Genomics and Translational Medicine/Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Cristina Selicean
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Sonia Cismas
- c Department of Genetics , Victor Babes University of Medicine and Pharmacy , Timisoara , Romania.,d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Anca Jurj
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mirela Marian
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Delia Dima
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania
| | - Sergiu Pasca
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Bobe Petrushev
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Vlad Moisoiu
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Wilhelm-Thomas Micu
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Anna Vischer
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Kanza Arifeen
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Sonia Selicean
- d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Mihnea Zdrenghea
- a Department of Hematology , Ion Chiricuta Clinical Cancer Center , Cluj Napoca , Romania.,d Department of Hematology , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Horia Bumbea
- f Department of Hematology , Carol Davila University of Medicine and Pharmacy , Bucharest , Romania.,g Department of Hematology , University Clinical Hospital , Bucharest , Romania
| | - Alina Tanase
- h Department of Stem Cell Transplantation , Fundeni Clinical Institute , Bucharest , Romania
| | - Ravnit Grewal
- i South African Medical Research Council Bioinformatics Unit , The South African National Bioinformatics Institute (SANBI), University of the Western Cape , Bellville , South Africa
| | - Laura Pop
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
| | - Carmen Aanei
- j Hematology Laboratory, Pole de Biologie-Pathologie , University Hospital of St. Etienne , St. Etienne , France
| | - Ioana Berindan-Neagoe
- e Research Center for Functional Genomics and Translational Medicine , Iuliu Hatieganu University of Medicine and Pharmacy , Cluj Napoca , Romania
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Strati P, Jain N, O'Brien S. Chronic Lymphocytic Leukemia: Diagnosis and Treatment. Mayo Clin Proc 2018; 93:651-664. [PMID: 29728204 DOI: 10.1016/j.mayocp.2018.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/30/2018] [Accepted: 03/02/2018] [Indexed: 12/27/2022]
Abstract
The complexity of the treatment of patients with chronic lymphocytic leukemia has increased substantially over the past several years as a consequence of the advent of novel biological agents such as ibrutinib, idelalisib, and venetoclax, as well as increasingly potent anti-CD20 monoclonal antibodies. In addition, the identification of molecular predictive markers and the introduction of more sensitive and sophisticated techniques to assess minimal residual disease have allowed optimization of the use of chemoimmunotherapy and targeted therapies and may become standard of care in the future. This review summarizes the diagnosis, prognostication, and treatment of patients with chronic lymphocytic leukemia with emphasis on new prognostic and predictive factors and novel treatment strategies.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
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Affiliation(s)
- Paolo Strati
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA.
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Salles G, Barrett M, Foà R, Maurer J, O'Brien S, Valente N, Wenger M, Maloney DG. Rituximab in B-Cell Hematologic Malignancies: A Review of 20 Years of Clinical Experience. Adv Ther 2017; 34:2232-2273. [PMID: 28983798 PMCID: PMC5656728 DOI: 10.1007/s12325-017-0612-x] [Citation(s) in RCA: 369] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 10/31/2022]
Abstract
Rituximab is a human/murine, chimeric anti-CD20 monoclonal antibody with established efficacy, and a favorable and well-defined safety profile in patients with various CD20-expressing lymphoid malignancies, including indolent and aggressive forms of B-cell non-Hodgkin lymphoma. Since its first approval 20 years ago, intravenously administered rituximab has revolutionized the treatment of B-cell malignancies and has become a standard component of care for follicular lymphoma, diffuse large B-cell lymphoma, chronic lymphocytic leukemia, and mantle cell lymphoma. For all of these diseases, clinical trials have demonstrated that rituximab not only prolongs the time to disease progression but also extends overall survival. Efficacy benefits have also been shown in patients with marginal zone lymphoma and in more aggressive diseases such as Burkitt lymphoma. Although the proven clinical efficacy and success of rituximab has led to the development of other anti-CD20 monoclonal antibodies in recent years (e.g., obinutuzumab, ofatumumab, veltuzumab, and ocrelizumab), rituximab is likely to maintain a position within the therapeutic armamentarium because it is well established with a long history of successful clinical use. Furthermore, a subcutaneous formulation of the drug has been approved both in the EU and in the USA for the treatment of B-cell malignancies. Using the wealth of data published on rituximab during the last two decades, we review the preclinical development of rituximab and the clinical experience gained in the treatment of hematologic B-cell malignancies, with a focus on the well-established intravenous route of administration. This article is a companion paper to A. Davies, et al., which is also published in this issue. FUNDING F. Hoffmann-La Roche Ltd., Basel, Switzerland.
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Affiliation(s)
- Gilles Salles
- Hématologie, Hospices Civils de Lyon and Université de Lyon, Pierre-Bénite, Lyon, France.
| | | | - Robin Foà
- Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | | | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA, USA
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11
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Maintenance Therapies in Indolent Lymphomas: should Recent Data Change the Standard of Care? Curr Treat Options Oncol 2017; 18:16. [PMID: 28286923 DOI: 10.1007/s11864-017-0459-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OPINION STATEMENT The overall benefit of maintenance therapy for patients with an indolent lymphoma continues to go unanswered. A myriad of variables contribute to the lack of clear clinical guidance. First, the disease course is slow and treatment may not be required for years, requiring a long follow-up to prospectively study. Second, due to the long lag time from study initiation to conclusion, many of the induction therapies used at the onset of the study may not be favored at present, providing a conclusion that cannot be reconciled with current clinical practice. For example, bendamustine and rituximab are typically the favored initial treatment agents in follicular lymphoma, which was not true when many maintenance trials were initiated. Third, several studies' inclusion criteria allow for patient enrollment at both initial diagnosis as well as at disease recurrence. In some studies, patients who are asymptomatic are started on therapy, counter to the accepted watch and wait approach. This contributes to the difficulty of generalizing results. The question of the benefit of maintenance therapy has been studied enough, and there may not be a smoking gun in the foreseeable future. However, what does hold promise is focusing on the patients with minimum residual disease after conclusion of chemotherapy. This may be a population that could receive benefit from a prolonged treatment approach. In the meantime, maintenance therapy should not be used in all patients, and the rationale for use should be data-driven, as well as an assessment of a patient's potential intolerability of cytotoxic chemotherapy.
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12
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Moccia AA, Zucca E, Ghielmini M. Is there a role for a maintenance rituximab in indolent lymphoproliferative diseases other than follicular lymphoma? Leuk Lymphoma 2016; 58:30-36. [PMID: 27813427 DOI: 10.1080/10428194.2016.1248963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Rituximab (R) is an anti-CD20 monoclonal antibody which has become an essential component for the treatment of B-cell lymphomas. When associated to chemotherapy it improves the outcome of the patients with diffuse large B-cell lymphoma, follicular lymphoma, and other lymphoproliferative diseases in comparison to chemotherapy alone. For patients with newly diagnosed follicular lymphoma achieving at least a partial response to initial immuno-chemotherapy, maintenance R was associated with an improvement in progression-free survival and a meta-analysis of randomized maintenance trials suggests an overall survival advantage. The role of maintenance R in other indolent diseases is less well-defined. In this article, we summarize the data available for this strategy in less frequent subtypes of indolent B-cell lymphomas.
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Affiliation(s)
- Alden A Moccia
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Emanuele Zucca
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Michele Ghielmini
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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13
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Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. LANCET HAEMATOLOGY 2016; 3:e407-14. [DOI: 10.1016/s2352-3026(16)30064-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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14
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Greil R, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Fridrik M, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Pleyer L, Melchardt T, Klingler A, Mayer J, Egle A. Rituximab maintenance versus observation alone in patients with chronic lymphocytic leukaemia who respond to first-line or second-line rituximab-containing chemoimmunotherapy: final results of the AGMT CLL-8a Mabtenance randomised trial. LANCET HAEMATOLOGY 2016; 3:e317-29. [PMID: 27374465 DOI: 10.1016/s2352-3026(16)30045-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND In many patients with chronic lymphocytic leukaemia requiring treatment, induction therapy with rituximab plus chemotherapy improves outcomes compared with chemotherapy alone. In this study we aimed to investigate the potential of rituximab maintenance therapy to prolong disease control in patients who respond to rituximab-containing induction regimens. METHODS In this randomised, international, multicentre, open-label, phase 3 clinical trial, we enrolled patients who had achieved a complete response (CR), CR with incomplete bone marrow recovery (CRi), or partial response (PR) to first-line or second-line rituximab-containing chemoimmunotherapy and randomly assigned them in a 1:1 ratio (central block randomisation in the electronic case report form system) to either intravenous rituximab 375 mg/m(2) every 3 months, or observation alone, for 2 years. Stratification was by country, line of treatment, type of chemotherapy added to the rituximab backbone, and degree of remission following induction. The primary endpoint was progression-free survival. Efficacy analysis was done in the intention-to-treat population. This is the final, event-triggered analysis. Final analysis was triggered by the occurrence of 92 events. This trial is registered with ClinicalTrials.gov, number NCT01118234. FINDINGS Between April 1, 2010, and Dec 23, 2013, 134 patients were randomised to rituximab and 129 to observation alone. Median observation times were 33·4 months (IQR 25·7-42·8) for the rituximab group and 34·0 months (25·4-41·9) for the observation group. Progression-free survival was significantly longer in the rituximab maintenance group (47·0 months, IQR 28·5-incalculable) than with observation alone (35·5 months, 95% CI 25·7-46·3; hazard ratio [HR] 0·50, 95% CI 0·33-0·75, p=0·00077). The incidence of grade 3-4 haematological toxicities other than neutropenia was similar in the two treatment groups. Grade 3-4 neutropenia occurred in 28 (21%) patients in the rituximab group and 14 (11%) patients in the observation group. Apart from neutropenia, the most common grade 3-4 adverse events were upper (five vs one [1%] patient in the observation group) and lower (three [2%] vs one [1%]) respiratory tract infection, pneumonia (nine [7%] vs two [2%]), thrombopenia (four [3%] vs four [3%]), neoplasms (five [4%] vs four [3%]), and eye disorders (four [3%] vs two [2%]). The overall incidence of infections of all grades was higher among rituximab recipients (88 [66%] vs 65 [50%]). INTERPRETATION Rituximab maintenance therapy prolongs progression-free survival in patients achieving at least a PR to induction with rituximab plus chemotherapy, and the treatment is well tolerated overall. Although it is associated with an increase in infections, there is no excess in infection mortality, suggesting that remission maintenance with rituximab is an effective and safe option in the management of chronic lymphocytic leukaemia in early treatment phases. FUNDING Arbeitsgemeinschaft Medikamentöse Tumortherapie gemeinnützige GmbH (AGMT), Roche.
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Affiliation(s)
- Richard Greil
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria.
| | - Petra Obrtlíková
- First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Lukáš Smolej
- Fourth Department of Internal Medicine-Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Králové, Hradec Králové, Czech Republic
| | - Tomáš Kozák
- Department of Internal Medicine-Hematology, Univ Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michael Steurer
- Department of Internal Medicine V, Medical University Innsbruck, Austria
| | - Johannes Andel
- Abteilung für Innere Medizin III, Landeskrankenhaus Steyr, Austria
| | - Sonja Burgstaller
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen GmbH, Austria
| | - Eva Mikušková
- Department of Hematooncology 2, National Cancer Institute, Bratislava, Slovakia
| | - Liana Gercheva
- Clinic of Hematology, University Hospital St Marina, Varna, Bulgaria
| | - Thomas Nösslinger
- Third Medical Department for Hematology and Oncology, Hanusch Krankenhaus der Wiener Gebietskrankenkasse, Vienna, Austria
| | - Tomáš Papajík
- Department of Hemato-oncology, University Hospital, Olomouc, Czech Republic
| | - Miriam Ladická
- Department of Clinical Oncology 1, National Cancer Institute, Bratislava, Slovakia
| | | | - Mikuláš Hrubiško
- Clinic of Hematology and Transfusiology, Slovak Medical University, University Hospital Bratislava, Slovakia
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaeology, Medical University Vienna, Austria
| | - Michael Fridrik
- Department of Internal Medicine 3, Kepler Universitätsklinikum GmbH, Med Campus III, Linz, Austria
| | - Martin Pecherstorfer
- University Hospital Krems, Karl Landsteiner Private University of Health Sciences, Department of Internal Medicine 2, Krems, Austria
| | - Eva Králiková
- Department of Hematology, FNsP F D Roosevelta, Banská Bystrica, Slovakia
| | | | - Emil Spasov
- Clinic of Hematology, UMHAT St George and Medical University, Plovdiv, Bulgaria
| | - Andreas Petzer
- Innere Medizin I, Krankenhaus der Barmherzigen Schwestern Linz, Linz, Austria
| | | | - Julian Raynov
- Clinic of Medical Hematology, Military Medical Academy, Sofia, Bulgaria
| | - Horst Oexle
- Innere Medizin, Landeskrankenhaus Hall, Austria
| | | | - Emília Flochová
- Department of Hematology and Transfusion, University Hospital Martin, Martin, Slovakia
| | | | - Olga Stehlíková
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Michael Doubek
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Petra Altenhofer
- Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Lisa Pleyer
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Thomas Melchardt
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Anton Klingler
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | - Jiří Mayer
- University Hospital, Faculty of Medicine and CEITEC, Brno, Czech Republic
| | - Alexander Egle
- Third Medical Department at the Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute (SCRI), Salzburg, Austria; Cancer Cluster Salzburg (CCS), Salzburg, Austria
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15
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Annovazzi P, Capobianco M, Moiola L, Patti F, Frau J, Uccelli A, Centonze D, Perini P, Tortorella C, Prosperini L, Lus G, Fuiani A, Falcini M, Martinelli V, Comi G, Ghezzi A. Rituximab in the treatment of Neuromyelitis optica: a multicentre Italian observational study. J Neurol 2016; 263:1727-35. [PMID: 27286847 DOI: 10.1007/s00415-016-8188-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/30/2016] [Accepted: 05/31/2016] [Indexed: 01/10/2023]
Abstract
Rituximab (RTX) efficacy in NMO is suggested by several case series. No consensus exists on optimal dosing strategies. At present the treatment schedules more frequently used are 375 mg/m2/week iv for 4 weeks (RTX-A) and 1000 mg iv twice, 2 weeks apart (RTX-B). Aim of this study is to confirm RTX efficacy and safety in the treatment of NMO and to evaluate whether a most favourable dosage regimen exists. Data on RTX-treated NMO patients were collected from 13 Italian Hospitals. 73 patients (64 F), were enlisted. RTX-A was administered in 42/73 patients, RTX-B in 31/73. Median follow-up was 27 months (range 7-106). Mean relapse rate in the previous year before RTX start was 2.2 ± 1.3 for RTX-A and 2.3 ± 1.2 for RTX-B. ARR in the first year of treatment was 0.8 ± 0.9 for RTX-A and 0.2 ± 0.4 for RTX-B, in the second year of treatment was 0.9 ± 1.5 for RTX-A and 0.4 ± 0.8 for RTX-B patients (p = 0.001 for the first year, ns (0.09) for the second year). RTX-B was more effective in delaying the occurrence of a relapse (HR 2.2 (95 % IC 1.08-4.53) p = 0.02). Adverse events were described in 19/73 patients (mainly urinary tract and respiratory infections, and infusion reactions). Two deaths were reported in severely disabled patients. Though with the limitations of an observational study, our data support RTX efficacy in NMO and suggest that high dose pulses might be more effective than a more fractioned dose.
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Affiliation(s)
- Pietro Annovazzi
- Multiple Sclerosis Study Center, ASST Valle Olona, PO di Gallarate (VA), Italy.
| | - M Capobianco
- Regional MS Center, University Hospital S. Luigi Gonzaga, Orbassano (TO), Italy
| | - L Moiola
- Department of Neurology, Scientific Institute H. San Raffaele, University Vita-Salute, Milan, Italy
| | - F Patti
- Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - J Frau
- Multiple Sclerosis Center, University of Catania, Catania, Italy
| | - A Uccelli
- Department of Neurosciences Ophtalmology and Genetics, University of Genoa, Genoa, Italy
| | - D Centonze
- Department of Neurology I and neurorehabilitation, IRCCS Neuromed, Pozzilli (IS), Italy
- Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - P Perini
- Department of Neurology, AO University of Padova, Padua, Italy
| | - C Tortorella
- Departments of Neurological and Psychiatric Sciences, University of Bari, Bari, Italy
| | - L Prosperini
- Department of Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - G Lus
- Department of Neurological Sciences, School of Medicine, Second University of Naples, Policlinico Federico II, Naples, Italy
| | - A Fuiani
- Department of Neurosciences, Multiple Sclerosis Unit, General Hospital, "OORR", Foggia, Italy
| | - M Falcini
- Multiple Sclerosis Center, Ospedale Misericordia e Dolce, Prato, Italy
| | - V Martinelli
- Department of Neurology, Scientific Institute H. San Raffaele, University Vita-Salute, Milan, Italy
| | - G Comi
- Multiple Sclerosis Study Center, ASST Valle Olona, PO di Gallarate (VA), Italy
- Department of Neurology, Scientific Institute H. San Raffaele, University Vita-Salute, Milan, Italy
| | - A Ghezzi
- Multiple Sclerosis Study Center, ASST Valle Olona, PO di Gallarate (VA), Italy
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16
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Awan FT, Jones JA, Maddocks K, Poi M, Grever MR, Johnson A, Byrd JC, Andritsos LA. A phase 1 clinical trial of flavopiridol consolidation in chronic lymphocytic leukemia patients following chemoimmunotherapy. Ann Hematol 2016; 95:1137-43. [PMID: 27118540 DOI: 10.1007/s00277-016-2683-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/18/2016] [Indexed: 12/17/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) who receive chemoimmunotherapy and do not achieve complete remission experience significantly shortened progression-free interval (PFS). Additionally, the majority of patients treated for relapsed disease demonstrate evidence of measurable disease. Eradication of minimal residual disease (MRD) results in improved PFS and overall survival. Maintenance therapy might result in eradication of MRD and improve response duration but might be associated with an increase in incidence of infectious complications. Flavopiridol is a broad cyclin-dependent kinase (CDK) inhibitor with established safety and efficacy in patients with relapsed CLL, particularly patients with high-risk cytogenetic features. A pharmacologically derived schedule was utilized as consolidation therapy in this phase I study to assess the safety and feasibility of outpatient therapy with flavopiridol in patients with low tumor burden. Flavopiridol was administered as a 30-min loading dose of 30 mg/m(2) followed by a 4-h infusion of 30 mg/m(2) once weekly for 3 weeks every 5 weeks (1 cycle) for planned 2 cycles in ten patients. Therapy was extremely well tolerated and no patient developed acute tumor lysis syndrome. The most common toxicities were gastrointestinal. Of the patients, 22 % improved their response from a PR to CR. Eighty-eight percent experienced a reduction in tumor burden as measured by extent of bone marrow involvement including patients with del17p and complex karyotype. The study establishes the safety and efficacy of flavopiridol as consolidation therapy after chemoimmunotherapy for patients with CLL. Further evaluation is required in larger trials for the utility of CDK inhibitors as consolidation or maintenance strategies.Registration number at ClinicalTrials.gov: NCT00377104.
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Affiliation(s)
- Farrukh T Awan
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
| | - Jeffrey A Jones
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Kami Maddocks
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Ming Poi
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Michael R Grever
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Amy Johnson
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - John C Byrd
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA
| | - Leslie A Andritsos
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
- Starling Loving Hall, 320 W. 10th Avenue, Columbus, Ohio, 43210, USA.
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Robak T, Blonski JZ, Robak P. Antibody therapy alone and in combination with targeted drugs in chronic lymphocytic leukemia. Semin Oncol 2016; 43:280-90. [DOI: 10.1053/j.seminoncol.2016.02.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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18
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Wiestner A. PROLONGing remissions in patients with CLL. Lancet Oncol 2015; 16:1282-4. [PMID: 26377301 DOI: 10.1016/s1470-2045(15)00219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Adrian Wiestner
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20817, USA.
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19
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van Oers MHJ, Kuliczkowski K, Smolej L, Petrini M, Offner F, Grosicki S, Levin MD, Gupta I, Phillips J, Williams V, Manson S, Lisby S, Geisler C. Ofatumumab maintenance versus observation in relapsed chronic lymphocytic leukaemia (PROLONG): an open-label, multicentre, randomised phase 3 study. Lancet Oncol 2015; 16:1370-9. [PMID: 26377300 DOI: 10.1016/s1470-2045(15)00143-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ofatumumab is a human anti-CD20 monoclonal antibody that has proven efficacy as monotherapy in refractory chronic lymphocytic leukaemia. We assessed the efficacy and safety of ofatumumab maintenance treatment versus observation for patients in remission after re-induction treatment for relapsed chronic lymphocytic leukaemia. METHODS This open-label, multicentre, randomised phase 3 study enrolled patients aged 18 years or older from 130 centres in 24 countries who had chronic lymphocytic leukaemia in complete or partial remission after second-line or third-line treatment. Eligible patients had a WHO performance status of 0-2, had a response assessment within the previous 3 months, did not have refractory disease, autoimmune haemolytic anaemia requiring treatment, chronic or active infection requiring treatment, and had not previously received maintenance treatment or autologous or allogeneic stem-cell transplant. Using a randomisation list generated by a central computerised system and an interactive voice recognition system, we randomly assigned (1:1) patients to receive ofatumumab (300 mg followed by 1000 mg 1 week later and every 8 weeks for up to 2 years) or undergo observation. Randomisation was stratified by number and type of previous treatment and remission status after induction treatment (block size of four). Treatment assignment was open label. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. We report the results of a prespecified interim analysis after two-thirds of the planned study events (disease progression or death) had happened. This trial is closed to accrual but follow-up is ongoing. This trial is registered with ClinicalTrials.gov, number NCT00802737. FINDINGS Between May 6, 2010, and June 19, 2014, we enrolled 474 patients: 238 patients were randomly assigned to receive ofatumumab maintenance treatment and 236 to undergo observation. One (<1%) patient in the ofatumumab group did not receive the allocated intervention (withdrawal of consent). The median follow-up was 19·1 months (IQR 10·3-28·8). Progression-free survival was improved in patients assigned to the ofatumumab group (29·4 months, 95% CI 26·2-34·2) compared with those assigned to observation (15·2 months, 11·8-18·8; hazard ratio 0·50, 95% CI 0·38-0·66; p<0·0001). The most common grade 3 or higher adverse events up to 60 days after last treatment were neutropenia (56 [24%] of 237 patients in the ofatumumab group vs 23 [10%] of 237 in the observation group) and infections (31 [13%] vs 20 [8%]). 20 (8%) of 237 patients in the ofatumumab group and three (1%) of 237 patients in the observation group had adverse events that led to permanent discontinuation of treatment. Up to 60 days after last treatment, two deaths related to adverse events occurred in the ofatumumab treatment group and five deaths related to adverse events occurred in the observation group; no deaths were attributed to the study drug. INTERPRETATION These data are important for the development of optimum maintenance strategies in patients with relapsed chronic lymphocytic leukaemia, notably in the present era of targeted drugs, many of which are to be used until progression.
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Affiliation(s)
- Marinus H J van Oers
- Department of Hematology, Academisch Medisch Centrum, Amsterdam, Netherlands; The Haemato Oncology Foundation for Adults in the Netherlands (HOVON), Amsterdam, Netherlands.
| | | | - Lukáš Smolej
- 4th Department of Internal Medicine-Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University, Prague, Czech Republic
| | - Mario Petrini
- Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | | | - Sebastian Grosicki
- Department of Cancer Prevention, Faculty of Public Health, Silesian Medical University, Katowice, Poland
| | - Mark-David Levin
- The Haemato Oncology Foundation for Adults in the Netherlands (HOVON), Amsterdam, Netherlands; Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
| | - Ira Gupta
- GlaxoSmithKline, Collegeville, PA, USA
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Doubek M, Šmída M. Treatment of chronic lymphocytic leukemia with monoclonal antibodies, where are we heading? Expert Rev Hematol 2015; 8:743-64. [PMID: 26306923 DOI: 10.1586/17474086.2015.1079123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in the western world and monoclonal antibodies (mAbs) are important part of CLL treatment. The goal of this article was to summarize current literature on the position of mAbs in CLL treatment and to mention factors influencing effectiveness of mAbs in CLL. Several new mAbs have been developed and investigated in CLL over the past few years. Mainly anti-CD20 monoclonal antibodies are still used routinely in CLL therapy. Unfortunately, the clinical application of mAbs needs to be further improved. Novel combinations and sequences of mAbs with other compounds need to be studied in clinical trials in order to increase overall response rate and prolong remission duration. Mechanisms of action of mAbs or mechanisms of resistance to mAbs have to be also investigated to predict effectiveness of mAb in particular patient.
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Affiliation(s)
- Michael Doubek
- a 1 Department of Internal Medicine - Hematology and Oncology, University Hospital and Faculty of Medicine, Brno, Czech Republic.,b 2 Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
| | - Michal Šmída
- b 2 Central European Institute of Technology (CEITEC), Masaryk University, Brno, Czech Republic
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21
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Molica S. Highlights in the treatment of chronic lymphocytic leukemia from the 2014 meeting of the American Society of Hematology. Expert Rev Hematol 2015; 8:277-81. [PMID: 25804936 DOI: 10.1586/17474086.2015.1029450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The latest Annual Meeting of the American Society of Hematology, held in San Francisco, included data on novel-targeted agents active in the treatment of chronic lymphocytic leukemia (CLL). MABTENANCE and PROLONG study suggest that either rituximab or ofatumumab improves progression-free survival in CLL. According to final analysis of CLL-10 trial, rituximab and bendamustine may have a role in the upfront treatment of fit elderly patients. Further insight into the use of ibrutinib, a first-in-class covalent Bruton’s tyrosine kinase-inhibitor that is currently approved for patients with relapsed/refractory CLL and with del(17p), was also presented. Idelalisib, a selective inhibitor of PI3K delta, demonstrated its activity with manageable toxicity in previously untreated patients ≥65 years with CLL or small lymphocytic lymphoma. Finally, a series Phase I/II studies of BCL-2 inhibitor (i.e., venetoclax, GDC-0199) used alone or in combination provide promising results in patients with relapsed/refractory CLL.
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Affiliation(s)
- Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Viale Pio X - 88100 Catanzaro, Italy
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22
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Thompson PA, Shpall EJ, Keating MJ. Shifting paradigms in the treatment of chronic lymphocytic leukemia. Future Oncol 2015; 11:641-57. [PMID: 25686119 DOI: 10.2217/fon.14.288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The treatment of chronic lymphocytic leukemia (CLL) is evolving rapidly. Insight into the genetics and biology of the disease, including the importance of intracellular signaling pathways and interactions with the microenvironment has led to the development of rational targeted therapies which are having a major impact on the survival of patients with relapsed and high-risk disease. In addition, an exciting array of cellular therapies and immunotherapy options are in various stages of development. We review the current understanding of CLL genetics and biology, current treatment strategies in specific patient groups and opportunities for future treatment combinations which will bring the goal of cure or long-term disease control with minimal toxicity within reach for the majority of patients.
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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How to determine post-FCR therapy for cytogenetic risk-tailored elderly patients with chronic lymphocytic leukemia, maintenance rituximab or observation. Med Oncol 2014; 31:104. [DOI: 10.1007/s12032-014-0104-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 06/23/2014] [Indexed: 10/25/2022]
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24
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Bo MD, Del Principe MI, Pozzo F, Ragusa D, Bulian P, Rossi D, Capelli G, Rossi FM, Niscola P, Buccisano F, Bomben R, Zucchetto A, Maurillo L, de Fabritiis P, Amadori S, Gaidano G, Gattei V, Del Poeta G. NOTCH1 mutations identify a chronic lymphocytic leukemia patient subset with worse prognosis in the setting of a rituximab-based induction and consolidation treatment. Ann Hematol 2014; 93:1765-74. [PMID: 24923451 DOI: 10.1007/s00277-014-2117-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 05/20/2014] [Indexed: 11/26/2022]
Abstract
Induction therapy with fludarabine followed by rituximab and consolidation plus maintenance with rituximab improved response duration (RD) and overall survival (OS) in our patients with chronic lymphocytic leukemia (CLL). The aim of our study was to investigate the clinical impact of NOTCH1 mutations in this setting of patients. The study included 123 progressive CLL patients homogeneously assigned to first-line induction treatment with fludarabine followed by rituximab. Fifty-nine patients either in complete remission (CR) minimal residual disease positive (MRD+) after induction (n = 39) or in partial remission (PR, n = 20) underwent consolidation/maintenance therapy with rituximab. Sixteen patients in CR MRD + or PR underwent observation only. The presence of NOTCH1 mutations was investigated by amplification refractory mutation system (ARMS) PCR and by Sanger sequencing. NOTCH1 mutations occurred in 20 out of 123 (16.3 %) cases. Consolidated patients showed longer OS than unconsolidated patients (p = 0.030). Both NOTCH1 mutated and CR MRD+ or PR NOTCH1 mutated patients showed significantly shorter OS after treatment (p = 0.00014 and p = 0.0021, respectively). Moreover, NOTCH1 wild-type consolidated cases experienced significantly longer RD and OS than NOTCH1 mutated consolidated or not consolidated cases (p = 0.00001 and p = 0.018, respectively). Finally, the independent prognostic impact of NOTCH1 mutations for OS was confirmed in multivariate analysis (p < 0.001). The presence of NOTCH1 mutations identifies a CLL subset with worse prognosis in the setting of a rituximab-based induction and consolidation treatment.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Consolidation Chemotherapy
- Female
- Genes, Immunoglobulin
- Genes, p53
- Humans
- Immunophenotyping
- In Situ Hybridization, Fluorescence
- Kaplan-Meier Estimate
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Mutation
- Neoplasm Proteins/genetics
- Neoplasm, Residual
- Prognosis
- Proportional Hazards Models
- Prospective Studies
- Receptor, Notch1/genetics
- Remission Induction
- Rituximab
- Treatment Outcome
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
- ZAP-70 Protein-Tyrosine Kinase/genetics
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Affiliation(s)
- Michele Dal Bo
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico, I.R.C.C.S., Aviano, PN, Italy
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25
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Foà R, Del Giudice I, Cuneo A, Del Poeta G, Ciolli S, Di Raimondo F, Lauria F, Cencini E, Rigolin GM, Cortelezzi A, Nobile F, Callea V, Brugiatelli M, Massaia M, Molica S, Trentin L, Rizzi R, Specchia G, Di Serio F, Orsucci L, Ambrosetti A, Montillo M, Zinzani PL, Ferrara F, Morabito F, Mura MA, Soriani S, Peragine N, Tavolaro S, Bonina S, Marinelli M, De Propris MS, Starza ID, Piciocchi A, Alietti A, Runggaldier EJ, Gamba E, Mauro FR, Chiaretti S, Guarini A. Chlorambucil plus rituximab with or without maintenance rituximab as first-line treatment for elderly chronic lymphocytic leukemia patients. Am J Hematol 2014; 89:480-6. [PMID: 24415640 DOI: 10.1002/ajh.23668] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 12/30/2013] [Accepted: 01/08/2014] [Indexed: 12/11/2022]
Abstract
In a phase II trial, we evaluated chlorambucil and rituximab (CLB-R) as first-line induction treatment with or without R as maintenance for elderly chronic lymphocytic leukemia (CLL) patients. Treatment consisted of eight 28-day cycles of CLB (8 mg/m(2) /day, days 1-7) and R (day 1 of cycle 3, 375 mg/m(2) ; cycles 4-8, 500 mg/m(2) ). Responders were randomized to 12 8-week doses of R (375 mg/m(2) ) or observation. As per intention-to-treat analysis, 82.4% (95% CI, 74.25-90.46%) of 85 patients achieved an overall response (OR), 16.5% a complete response (CR), 2.4% a CR with incomplete bone marrow recovery. The OR was similar across Binet stages (A 86.4%, B 81.6%, and C 78.6%) and age categories (60-64 years, 92.3%; 65-69, 85.2%; 70-74, 75.0%; ≥75, 81.0%). CLB-R was well tolerated. After a median follow-up of 34.2 months, the median progression-free survival (PFS) was 34.7 months (95% CI, 33.1-39.5). TP53 abnormalities, complex karyotype, and low CD20 gene expression predicted lack of response; SF3B1 mutation and BIRC3 disruption low CR rates. IGHV mutations significantly predicted PFS. R maintenance tended towards a better PFS than observation and was safe and most beneficial for patients in partial response and for unmutated IGHV cases. CLB-R represents a promising option for elderly CLL patients.
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Affiliation(s)
- Robin Foà
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Ilaria Del Giudice
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Antonio Cuneo
- University of Ferrara, Arcispedale Sant'Anna; Ferrara Italy
| | - Giovanni Del Poeta
- Division of Hematology; S. Eugenio Hospital and University of Tor Vergata; Rome Italy
| | - Stefania Ciolli
- Division of Hematology; University of Florence; Florence Italy
| | | | | | | | | | | | - Francesco Nobile
- Hematology Unit, Azienda Ospedaliera Bianchi Melacrino Morelli; Reggio Calabria Italy
| | - Vincenzo Callea
- Hematology Unit, Azienda Ospedaliera Bianchi Melacrino Morelli; Reggio Calabria Italy
| | | | | | - Stefano Molica
- Oncologia Medica, Azienda Ospedaliera Pugliese Ciaccio; Catanzaro Italy
| | - Livio Trentin
- Dipartimento Medicina e Clinica Sperimentale; University of Padua; Padua Italy
| | - Rita Rizzi
- Hematology; University of Bari; Bari Italy
| | | | - Francesca Di Serio
- Clinical Pathology Unit; Azienda Ospedaliero-Universitaria Consorziale Policlinico; Bari Italy
| | - Lorella Orsucci
- Oncology-Section of Hematology; San Giovanni Battista Hospital; Turin Italy
| | - Achille Ambrosetti
- Hematology Section; Department of Medicine; University of Verona; Verona Italy
| | - Marco Montillo
- Division of Hematology; Niguarda Ca' Granda Hospital; Milan Italy
| | - Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology, “L. e A. Seràgnoli”, University of Bologna; Bologna Italy
| | - Felicetto Ferrara
- Cardarelli Hospital, Hematology and Stem Cell Transplantation Unit; Naples Italy
| | | | | | - Silvia Soriani
- Laboratory of Cytogenetic; Ospedale Niguarda; Milan Italy
| | - Nadia Peragine
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Simona Tavolaro
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Silvia Bonina
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Marilisa Marinelli
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | | | - Irene Della Starza
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | | | | | | | | | | | - Sabina Chiaretti
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
| | - Anna Guarini
- Department of Cellular Biotechnologies and Hematology; Sapienza University; Rome Italy
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26
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Abstract
In this issue of Blood, Abrisqueta and colleagues report on the outcomes of a phase 2 clinical trial evaluating rituximab maintenance therapy in chronic lymphocytic leukemia (CLL) patients after treatment with rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM).
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27
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Rein LA, Sung AD, Rizzieri DA. New approaches to manipulate minimal residual disease after allogeneic stem cell transplantation. Int J Hematol Oncol 2013; 2. [PMID: 24303095 DOI: 10.2217/ijh.13.4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Minimal residual disease (MRD) is a complex topic that has been studied extensively in hematologic malignancies given its clinical implications related to prognosis. However, methods to monitor and treat MRD, especially after stem cell transplantation, are not well defined and vary in different disease processes. Alternative transplant strategies, such as reduced-intensity conditioning, have altered the way we assess and address MRD after transplantation. Development of new diagnostic tools have allowed for higher sensitivity and specificity of testing. Both targeted chemotherapeutic agents and immunotherapies have been developed to treat MRD in hopes of improving patient outcomes. This article aims to address ways to define and manipulate MRD specifically after stem cell transplantation.
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Affiliation(s)
- Lindsay Am Rein
- Division of Hematologic Malignancies & Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
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28
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Rituximab maintenance after first-line therapy with rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) for chronic lymphocytic leukemia. Blood 2013; 122:3951-9. [PMID: 24124086 DOI: 10.1182/blood-2013-05-502773] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The effectiveness of rituximab maintenance therapy in the treatment of chronic lymphocytic leukemia has been investigated in a phase 2 clinical trial that included an initial treatment with rituximab 500 mg/m2 on day 1 (375 mg/m2 the first cycle), fludarabine 25 mg/m2 on days 1 to 3, cyclophosphamide 200 mg/m2 on days 1 to 3, and mitoxantrone 6 mg/m2 on day 1 (R-FCM), for 6 cycles, followed by a maintenance phase with rituximab 375 mg/m2 every 3 months for 2 years. Sixty-seven patients having achieved complete response (CR) or partial response (PR) with R-FCM were given maintenance therapy. At the end of maintenance, 40.6% of patients were in CR with negative minimal residual disease (MRD), 40.6% were in CR MRD-positive, 4.8% remained in PR, and 14% were considered failures. Six of 29 patients (21%) who were in CR MRD-positive or in PR after R-FCM improved their response upon rituximab maintenance. The 4-year progression-free survival (PFS) and overall survival rates were 74.8% and 93.7%, respectively. MRD status after R-FCM induction was the strongest predictor of PFS. Maintenance with rituximab after R-FCM improved the quality of the response, particularly in patients MRD-positive after initial treatment, and obtained a prolonged PFS. This trial was registered at www.clinicaltrialsregister.eu as identifier #2005-001569-33.
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29
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Cuthill K, Devereux S. How I treat patients with relapsed chronic lymphocytic leukaemia. Br J Haematol 2013; 163:423-35. [DOI: 10.1111/bjh.12549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/29/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Kirsty Cuthill
- Department of Haematological Medicine; Kings College; London UK
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30
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Ofatumumab in rituximab-refractory autoimmune hemolytic anemia associated with chronic lymphocytic leukemia: a case report and review of literature. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13:511-3. [PMID: 23726016 DOI: 10.1016/j.clml.2013.02.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 12/29/2012] [Accepted: 02/01/2013] [Indexed: 01/13/2023]
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31
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Stephens DM, Byrd JC. Improving the Treatment Outcome of Patients with Chronic Lymphocytic Leukemia Through Targeted Antibody Therapy. Hematol Oncol Clin North Am 2013; 27:303-27. [DOI: 10.1016/j.hoc.2012.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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32
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Kempin S. Update on Chronic Lymphocytic Leukemia: Overview of New Agents and Comparative Analysis. Curr Treat Options Oncol 2013; 14:144-55. [DOI: 10.1007/s11864-013-0229-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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33
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Jain P, O'Brien S. Anti-CD20 monoclonal antibodies in chronic lymphocytic leukemia. Expert Opin Biol Ther 2013; 13:169-82. [PMID: 23256681 DOI: 10.1517/14712598.2012.735655] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The last decade has witnesd immense progress in the treatment of chronic lymphocytic leukemia (CLL). Chemoimmunotherapy (CIT) combining rituximab and fludarabine with cyclophosphamide (FCR) in the frontline setting has clearly been shown to improve outcomes in patients with CLL. Building on the success achieved with rituximab, other anti-CD20 monoclonal antibodies (mAbs) are being investigated. Novel bioengineering techniques have helped in the development of anti-CD20 mAbs. One antibody, ofatumumab, was recently approved for the treatment of refractory CLL. A type II anti-CD20 mAb, GA-101 (obinutuzumab), is currently in clinical trials. This short review focuses on ongoing clinical trials of anti-CD20 mAbs in CLL. AREAS COVERED Literature search was performed using PubMed ( www.clinicaltrials.gov (till August 2012)), and recent American Society of Clinical Oncology (ASCO), American Society of Hematology (ASH), European Hematology association (EHA), International workshop on CLL (iwCLL) abstracts, using the primary search terms 'anti-CD20 monoclonal antibody' with/without CLL. Articles were chosen on the basis of relevance of anti-CD20 mAbs to CLL therapy. EXPERT OPINION Rituximab, the prototype anti-CD20 mAb, forms the core of CIT in CLL. The success of rituximab and ofatumumab has led investigators to evaluate other anti-CD20 mAbs in the treatment of CLL.
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Affiliation(s)
- Preetesh Jain
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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34
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A look into the future: can minimal residual disease guide therapy and predict prognosis in chronic lymphocytic leukemia? Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.97.3798195] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Over the past 2 decades, dramatic improvements in the efficacy of treatments for chronic lymphocytic leukemia have led to progressively higher percentages of clinical complete remissions. A molecular eradication of the leukemia has become not only a desirable, but also an achievable, end point that needs to be evaluated within clinical trials. The assessment of complete remission only at the clinical and morphological level is insufficient, at least for physically fit patients. The detection of minimal residual disease (MRD) in chronic lymphocytic leukemia has become feasible using PCR-based or flow cytometric techniques that reproducibly allow reaching the detection level of less than 1 leukemic cell per 10 000 leukocytes (10−4), the level currently defined as MRD− status. Emerging data indicate that the MRD status during and at the end of treatment is one of the most powerful predictors of progression-free and overall survival. This predictor appears to be independent of clinical response, type or line of therapy, and known biological markers. For these reasons, the time is ripe to test the use of MRD as a surrogate marker of clinical end points and as a real-time marker of efficacy and/or resistance to the administered therapies. In the near future, clinical trials will determine whether MRD assessment can be used for guiding therapy, either to improve quality of responses through consolidation or to prevent relapses through preemptive therapies based on the reappearance of MRD.
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35
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36
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Plander M, Skrapits J, Bozsó T, Szendrei T, Iványi JL. [Detection and impact of minimal residual disease on outcome of chronic lymphocytic leukemia]. Orv Hetil 2012; 153:1622-8. [PMID: 23045312 DOI: 10.1556/oh.2012.29458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Minimal residual disease is associated with longer overall survival in patients with chronic lymphocytic leukemia. AIM The aim of the authors was to determine the clinical significance of remission and minimal residual disease on the survival of patients with chronic lymphocytic leukemia. METHODS Data from 42 first-line treated patients with chronic lymphocytic leukemia were analyzed. Minimal residual disease was determined by flow cytometry. RESULTS Overall response and complete remission was achieved in 91%, 86%, 100% and 87%, 0%, 60% of patients with fludarabine-based combinations, single-agent fludarabine and cyclophosphamide + vincristin + prednisolone regimen, respectively. Minimal residual disease eradication was feasible only with fludarabine-based combinations in 60% of these cases. The ratio of minimal residual disease was 0.5% on average. During a median follow-up period lasting 30 months, the overall survival of patients with fludarabine-resistant disease proved to be significantly shorter (p = 0.04), while complete remission without minimal residual disease was associated with significantly longer progression free survival (p = 0.02). CONCLUSION Only fludarabine-based combinations were able to eradicate minimal residual disease in patients with chronic lymphocytic leukemia. Complete remission without minimal residual disease may predict longer progression free survival in these patients.
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Affiliation(s)
- Márk Plander
- Vas Megyei Markusovszky Kórház, Egyetemi Oktatókórház Nonprofit Zrt. Haematologiai és Haemostaseologiai Osztály, Szombathely.
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37
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Oscier D, Dearden C, Eren E, Erem E, Fegan C, Follows G, Hillmen P, Illidge T, Matutes E, Milligan DW, Pettitt A, Schuh A, Wimperis J. Guidelines on the diagnosis, investigation and management of chronic lymphocytic leukaemia. Br J Haematol 2012; 159:541-64. [PMID: 23057493 DOI: 10.1111/bjh.12067] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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39
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Abdulla NE, Ninan MJ, Markowitz AB. Rituximab: current status as therapy for malignant and benign hematologic disorders. BioDrugs 2012; 26:71-82. [PMID: 22339395 DOI: 10.2165/11599500-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Rituximab is a chimeric monoclonal antibody targeting the pan-B-cell antigen CD20 and was the first monoclonal antibody approved for clinical use in the treatment of cancer. Since its first approval by the FDA in 1997, investigators have continued to explore a variety of clinical conditions in which rituximab has proven effective with minimal toxicity. Rituximab, as monotherapy or in combination with chemotherapy, has been studied extensively in untreated and relapsed/refractory settings as both induction and maintenance therapy for the treatment of CD20-positive lymphomas and chronic lymphocytic leukemia, in addition to non-malignant hematologic disorders including autoimmune hemolytic anemia and immune thrombocytopenic purpura. Here we discuss the clinical development of rituximab with a review of the efficacy data from clinical trials and its current status in the practice of hematology and oncology.
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Affiliation(s)
- Nihal E Abdulla
- Division of Hematology/Oncology, University of Texas Medical Branch, Galveston, TX 77555-0565, USA
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40
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Sellner L, Dietrich S, Dreger P, Glimm H, Zenz T. Can prognostic factors be used to direct therapy in chronic lymphocytic leukemia? Curr Hematol Malig Rep 2012; 7:3-12. [PMID: 22237849 DOI: 10.1007/s11899-011-0110-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic lymphocytic leukemia (CLL) shows a heterogeneous clinical course, which can be explained in part by prognostic factors. Most patients do not need treatment at the time of first diagnosis. The identification of prognostic factors is of major interest if strategies can be devised to treat patients according to their individual risk profile or biological subgroup. Currently, in spite of a wealth of prognostic factors, individualized treatment approaches in different genetic or risk groups are the exemption in CLL. This review summarizes the most important prognostic and predictive factors in CLL, with particular emphasis on factors affecting treatment decisions in clinical trials and routine practice.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/analysis
- Humans
- Induction Chemotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Mutation
- Phenotype
- Predictive Value of Tests
- Prognosis
- Risk Assessment
- Risk Factors
- Stem Cell Transplantation
- Time Factors
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Affiliation(s)
- Leopold Sellner
- Department of Medicine V, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany
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Herpesviridae Viral Infections After Chemotherapy Without Antiviral Prophylaxis in Patients With Malignant Lymphoma. Am J Clin Oncol 2012; 35:146-50. [DOI: 10.1097/coc.0b013e318209aa41] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Böttcher S, Ritgen M, Fischer K, Stilgenbauer S, Busch RM, Fingerle-Rowson G, Fink AM, Bühler A, Zenz T, Wenger MK, Mendila M, Wendtner CM, Eichhorst BF, Döhner H, Hallek MJ, Kneba M. Minimal Residual Disease Quantification Is an Independent Predictor of Progression-Free and Overall Survival in Chronic Lymphocytic Leukemia: A Multivariate Analysis From the Randomized GCLLSG CLL8 Trial. J Clin Oncol 2012; 30:980-8. [DOI: 10.1200/jco.2011.36.9348] [Citation(s) in RCA: 351] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose To determine the clinical significance of flow cytometric minimal residual disease (MRD) quantification in chronic lymphocytic leukemia (CLL) in addition to pretherapeutic risk factors and to compare the prognostic impact of MRD between the arms of the German CLL Study Group CLL8 trial. Patients and Methods MRD levels were prospectively quantified in 1,775 blood and bone marrow samples from 493 patients randomly assigned to receive fludarabine and cyclophosphamide (FC) or FC plus rituximab (FCR). Patients were categorized by MRD into low- (< 10−4), intermediate- (≥ 10−4 to <10−2), and high-level (≥ 10−2) groups. Results Low MRD levels during and after therapy were associated with longer progression-free survival (PFS) and overall survival (OS; P < .0001). Median PFS is estimated at 68.7, 40.5, and 15.4 months for low, intermediate, and high MRD levels, respectively, when assessed 2 months after therapy. Compared with patients with low MRD, greater risks of disease progression were associated with intermediate and high MRD levels (hazard ratios, 2.49 and 14.7, respectively; both P < .0001). Median OS was 48.4 months in patients with high MRD and was not reached for lower MRD levels. MRD remained predictive for OS and PFS in multivariate analyses that included the most important pretherapeutic risk markers in CLL. PFS and OS did not differ between treatment arms within each MRD category. However, FCR induced low MRD levels more frequently than FC. Conclusion MRD levels independently predict OS and PFS in CLL. Therefore, MRD quantification might serve as a surrogate marker to assess treatment efficacy in randomized trials before clinical end points can be evaluated.
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Affiliation(s)
- Sebastian Böttcher
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Matthias Ritgen
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Kirsten Fischer
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Stephan Stilgenbauer
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Raymonde M. Busch
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Günter Fingerle-Rowson
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Anna Maria Fink
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Andreas Bühler
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Thorsten Zenz
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael Karl Wenger
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Myriam Mendila
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Clemens-Martin Wendtner
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Barbara F. Eichhorst
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Hartmut Döhner
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael J. Hallek
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
| | - Michael Kneba
- Sebastian Böttcher, Matthias Ritgen, and Michael Kneba, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel; Kirsten Fischer, Günter Fingerle-Rowson, Anna Maria Fink, Clemens-Martin Wendtner, Barbara F. Eichhorst, and Michael J. Hallek, University of Cologne, Cologne; Stephan Stilgenbauer, Andreas Bühler, Thorsten Zenz, and Hartmut Döhner, University of Ulm, Ulm; Raymonde M. Busch, Technical University, Munich, Germany; and Michael Karl Wenger and Myriam Mendila, Hoffmann-La Roche, Basel,
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Jaglowski S, Jones JA. Choosing first-line therapy for chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2012; 11:1379-90. [PMID: 21929312 DOI: 10.1586/era.11.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Chronic lymphocytic leukemia (CLL) exhibits a highly variable natural history, but the addition of genomic risk stratification to traditional clinical staging systems has begun to explain the heterogeneous clinical course. Overall response to treatment has significantly improved over the past three decades and for the first time, a survival benefit has been demonstrated with the use of monoclonal antibodies in combination with cytotoxic chemotherapy. Newer therapeutic strategies have abrogated the adverse prognosis associated with some higher risk features, but other genetic subgroups remain at high risk for rapid disease progression and early mortality. Patients at advanced age or with significant comorbidity constitute a large proportion of the CLL population and present unique clinical challenges. This article will discuss the evolution of contemporary therapeutic approaches to the initial treatment of CLL, and highlight the ways in which risk-adapted therapeutic strategies are improving clinical outcomes.
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Affiliation(s)
- Samantha Jaglowski
- Division of Hematology, Ohio State University, A352 Starling-Loving Hall, 320 West 10th Avenue, Columbus, OH 43210, USA
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Marti GE. The detection of minimal residual disease status in chronic lymphocytic leukemia. CYTOMETRY PART B-CLINICAL CYTOMETRY 2011; 80:344-5. [PMID: 22002904 DOI: 10.1002/cyto.b.20625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
MESH Headings
- Antigens, CD19/immunology
- B-Lymphocytes/chemistry
- B-Lymphocytes/immunology
- Bone Marrow Cells/chemistry
- Bone Marrow Cells/immunology
- CD5 Antigens/immunology
- Humans
- Immunophenotyping/standards
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Neoplasm, Residual/diagnosis
- Reagent Kits, Diagnostic/standards
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Van Den Neste E, Letestu R, Aurran-Schleinitz T, Ysebaert L, Feugier P, Leprêtre S, Dartigeas C. Post-remission intervention with alemtuzumab or rituximab to eradicate minimal residual disease in chronic lymphocytic leukemia: where do we stand? Leuk Lymphoma 2011; 53:362-70. [PMID: 21854093 DOI: 10.3109/10428194.2011.608450] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The introduction of purine nucleoside analogs, later in combination with alkylating moieties and anti-CD20 immunotherapy, has profoundly improved the response rate and response duration in patients with chronic lymphocytic leukemia (CLL). The quality of clinical response following treatment may be improved to a level where residual leukemic cells become undetectable. As patients with this type of response appear to have extended survival rates, minimal residual disease (MRD) eradication is considered a new objective in CLL treatment with the aim of improving progression-free survival (PFS) and potentially overall survival (OS). This review therefore aims to overview the prognostic value of MRD eradication in CLL, the role of post-remission intervention with "passive" immunotherapy (alemtuzumab or rituximab) so as to eliminate persistent MRD or prevent MRD relapse, the impact of these strategies on disease-free survival and their possible adverse consequences. The data indicate a potential for post-remission alemtuzumab or rituximab to prolong PFS in CLL, although more investigations and longer follow-up are required before MRD-guided strategies can be recommended outside of clinical trials.
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Affiliation(s)
- Eric Van Den Neste
- Service d'Hématologie, Cliniques universitaires UCL Saint-Luc, Brussels, Belgium.
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Chow KU, Kim SZ, von Neuhoff N, Schlegelberger B, Stilgenbauer S, Wunderle L, Cordes HJ, Bergmann L. Clinical efficacy of immunochemotherapy with fludarabine, epirubicin and rituximab in the treatment for chronic lymphocytic leukaemia and prolymphocytic leukaemia. Eur J Haematol 2011; 87:426-33. [PMID: 21749447 DOI: 10.1111/j.1600-0609.2011.01680.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite some considerable progress in the therapy for chronic lymphocytic leukaemia (CLL) owing to fludarabine-based regimens and rituximab, no curative treatment is available so far. We conducted an explorative phase II study in patients with CLL, prolymphocytic leukaemia (PLL) and leukaemic lymphoplasmacytic lymphoma (LL) with the combination of fludarabine, epirubicin and rituximab (FER) to improve the complete remission (CR) rate and progression-free survival (PFS). Fludarabine 25 mg/m(2) was administered i.v. on days 1-5 and epirubicin 25 mg/m(2) i.v. on days 4 and 5, and rituximab was added at a dose of 375 mg/m(2) i.v. day 1 in the first cycle and at a dose of 500 mg/m(2) in all consecutive cycles. Patients exhibiting responsive disease after FER were eligible to receive maintenance therapy of up to 12 cycles of rituximab 375 mg/m(2) bimonthly. Forty-four patients (38 CLL, 4 PLL and 2 LL) with a median age of 65 yrs (43-84 yrs) were evaluable. Seventeen patients with CLL had stage Binet C, 14 Binet B and seven symptomatic or rapid progressive stage Binet A. Cytogenetic features showed normal karyotype in nine cases, an isolated deletion (del) 13q in 12 patients, trisomy 12 in 7, del 11 in two and del 17p in 4. Half of the patients (48%) had mutated IgVH genes. Treatment with FER achieved an overall response rate of 95%, including 63% CRs and 32% PRs. Haematological toxicity was considerable. After a median follow-up period of 34 months (range: 8-84 months), median PFS was 61 months and overall survival was yet not reached. All patients with PLL and LL achieved CR. The data support the high efficacy of the combination of rituximab with chemotherapy (FE) and are suggestive of possible benefit with rituximab maintenance therapy for PFS and DFS.
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Affiliation(s)
- Kai Uwe Chow
- Hematology and Oncology, Frankfurt Medical Clinic II, Johann-Wolfgang-Goethe University Hospital, Theodor-Stern-Kai 7, Frankfurt, Germany
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Interleukin-15 enhances rituximab-dependent cytotoxicity against chronic lymphocytic leukemia cells and overcomes transforming growth factor beta-mediated immunosuppression. Exp Hematol 2011; 39:1064-71. [PMID: 21864486 DOI: 10.1016/j.exphem.2011.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 07/12/2011] [Accepted: 08/05/2011] [Indexed: 01/28/2023]
Abstract
Chemoimmunotherapy with anti-CD20 monoclonal antibody rituximab is increasingly used for the treatment of patients with chronic lymphocytic leukemia (CLL). Antibody-dependent cytotoxicity (ADCC) is one of the most important mechanisms of action of rituximab against B-cell malignancies. We studied ways to increase the cytotoxic effect of rituximab on CLL cells by enhancing ADCC. Peripheral blood mononuclear cell (PBMC) or purified natural killer (NK) cells from healthy donors were activated with interleukin-15 (IL-15) and cultured with rituximab-coated CLL cells, and ADCC was evaluated using a (51)chromium release assay. The IL-15 significantly enhanced in vitro ADCC against CLL cells, and this effect was mainly mediated by NK cells. The IL-15 treated effector cells with the low affinity FcγRIIIA receptor (158FF) had an ADCC comparable to those with the high affinity FcγRIIIA form (158VF). In addition, IL-15 enhanced rituximab-mediated ADCC of CLL cells in the presence of transforming growth factor-beta. The IL-15 increases rituximab-mediated ADCC against CLL, and supports the use of such agents with the goal of improving clinical response to chemoimmunotherapy in patients with CLL.
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Abstract
Rituximab (Rituxan; iogen Idec, San Diego, CA, USA) is a human-mouse chimeric monoclonal antibody specific for CD20, a surface glycoprotein expressed on B lymphocytes. Administration of rituximab as a single agent to patients with chronic lymphocytic leukemia (CLL) has limited clinical activity, but generally does not eradicate leukemia from the marrow. However, when administered in combination with chemotherapy, rituximab can improve the survival of patients relative to those treated with chemotherapy alone. As a result of this, the US Food and Drug Administration approved the use of rituximab in previously untreated and previously treated CD20-positive CLL in combination with fludarabine monophosphate and cyclophosphamide. The results of clinical studies evaluating the activity of rituximab when used alone or in combination with other antileukemia agents for the treatment of this disease are reviewed here.
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Affiliation(s)
- Danelle F James
- Diversion of Hematology/Oncology, Moores UCSD Cancer Center, University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093-0820, USA.
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Abstract
Cancer immunotherapy consists of approaches that modify the host immune system, and/or the utilization of components of the immune system, as cancer treatment. During the past 25 years, 17 immunologic products have received regulatory approval based on anticancer activity as single agents and/or in combination with chemotherapy. These include the nonspecific immune stimulants BCG and levamisole; the cytokines interferon-α and interleukin-2; the monoclonal antibodies rituximab, ofatumumab, alemtuzumab, trastuzumab, bevacizumab, cetuximab, and panitumumab; the radiolabeled antibodies Y-90 ibritumomab tiuxetan and I-131 tositumomab; the immunotoxins denileukin diftitox and gemtuzumab ozogamicin; nonmyeloablative allogeneic transplants with donor lymphocyte infusions; and the anti-prostate cancer cell-based therapy sipuleucel-T. All but two of these products are still regularly used to treat various B- and T-cell malignancies, and numerous solid tumors, including breast, lung, colorectal, prostate, melanoma, kidney, glioblastoma, bladder, and head and neck. Positive randomized trials have recently been reported for idiotype vaccines in lymphoma and a peptide vaccine in melanoma. The anti-CTLA-4 monoclonal antibody ipilumumab, which blocks regulatory T-cells, is expected to receive regulatory approval in the near future, based on a randomized trial in melanoma. As the fourth modality of cancer treatment, biotherapy/immunotherapy is an increasingly important component of the anticancer armamentarium.
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Affiliation(s)
- Robert O Dillman
- Hoag Cancer Institute of Hoag Hospital , Newport Beach, California 92658, USA.
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