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Raucci F, Vernieri C, Di Tano M, Ligorio F, Blaževitš O, Lazzeri S, Shmahala A, Fragale G, Salvadori G, Varano G, Casola S, Buono R, Visco E, de Braud F, Longo VD. Cyclic Fasting-Mimicking Diet Plus Bortezomib and Rituximab Is an Effective Treatment for Chronic Lymphocytic Leukemia. Cancer Res 2024; 84:1133-1148. [PMID: 38241703 PMCID: PMC10982641 DOI: 10.1158/0008-5472.can-23-0295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 10/12/2023] [Accepted: 01/18/2024] [Indexed: 01/21/2024]
Abstract
Cyclic fasting-mimicking diet (FMD) is an experimental nutritional intervention with potent antitumor activity in preclinical models of solid malignancies. FMD cycles are also safe and active metabolically and immunologically in cancer patients. Here, we reported on the outcome of FMD cycles in two patients with chronic lymphocytic leukemia (CLL) and investigated the effects of fasting and FMD cycles in preclinical CLL models. Fasting-mimicking conditions in murine CLL models had mild cytotoxic effects, which resulted in apoptosis activation mediated in part by lowered insulin and IGF1 concentrations. In CLL cells, fasting conditions promoted an increase in proteasome activity that served as a starvation escape pathway. Pharmacologic inhibition of this escape mechanism with the proteasome inhibitor bortezomib resulted in a strong enhancement of the proapoptotic effects of starvation conditions in vitro. In mouse CLL models, combining cyclic fasting/FMD with bortezomib and rituximab, an anti-CD20 antibody, delayed CLL progression and resulted in significant prolongation of mouse survival. Overall, the effect of proteasome inhibition in combination with FMD cycles in promoting CLL death supports the targeting of starvation escape pathways as an effective treatment strategy that should be tested in clinical trials. SIGNIFICANCE Chronic lymphocytic leukemia cells resist fasting-mimicking diet by inducing proteasome activation to escape starvation, which can be targeted using proteasome inhibition by bortezomib treatment to impede leukemia progression and prolong survival.
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Affiliation(s)
- Franca Raucci
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Claudio Vernieri
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maira Di Tano
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
- Weill Cornell Medical College, Department of Medicine, Cornell University, New York, New York
| | - Francesca Ligorio
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Olga Blaževitš
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Samuel Lazzeri
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | | | - Giuseppe Fragale
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Giulia Salvadori
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Gabriele Varano
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Stefano Casola
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Roberta Buono
- Department of Molecular Biology and Biochemistry, University of California, Irvine, Irvine, California
- Longevity Institute, Davis School of Gerontology and Department of Biological Sciences, University of Southern California, Los Angeles, California
| | - Euplio Visco
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
| | - Filippo de Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Valter D. Longo
- IFOM ETS, the AIRC Institute of Molecular Oncology, Milan, Italy
- Longevity Institute, Davis School of Gerontology and Department of Biological Sciences, University of Southern California, Los Angeles, California
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Autore F, Fresa A, Innocenti I, Principe MID, Maglione R, Stefanizzi C, Pelliccia S, Romeo A, Cimino G, Papa E, Padua LD, Andriani A, Mengarelli A, Tafuri A, Ditto C, Mauro FR, Del Poeta G, Laurenti L. Correspondence in reference to the previously published manuscript: Reduction of cycles of bendamustine plus rituximab therapy in the cases with good response for indolent B-cell lymphomas. Hematol Oncol 2023; 41:571-573. [PMID: 35319789 DOI: 10.1002/hon.2989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Takezaki et al. analyzed the outcome of 57 patients with indolent lymphomas treated with Bendamustine plus Rituximab (BR) according to the number of cycles received, showing that patients who discontinued BR after four cycles had similar outcomes compared to patients who received five or six cycles. Considering the similarities but also the differences between indolent lymphomas and chronic lymphocytic leukemia (CLL), we enriched the results obtained with a cohort of CLL patients treated with BR starting from the experience of the Lazio region group on CLL. Out of 115 patients, 97 (84%) received 4-6 cycles of BR, while 18 (16%) received 1-3 cycles. The outcome of the group of patients who received at least 4 cycles was superior in terms of response rate (ORR 96% vs. ORR 83%, p = 0.041; CR 58% vs. CR 28%, p = 0.052 respectively) and PFS [median PFS 52.6 (40.3-64.9) versus 26.2 (19.3-33.0) months, p < 0.001]. The number of patients undergoing 4 cycles of BR (4-cycles group) and 5-6 cycles (over-4-cycles group) was 9 and 88, respectively. Compared to analysis conducted by the Japanese group in indolent lymphomas, in CLL we did not observe any difference between the outcome of the 4-cycles group and the over-4-cycles group in terms of ORR (89% vs. 97%, p = 0.268) and in survival [median PFS 40.8 (13.7-67.8) versus 52.6 (38.7-66.5) months, p = 0.117]. Moreover, we observed that patients who achieved a clinical CR showed overlapping outcomes with patients who received more than 4 cycles [CR vs. non-CR median PFS not reached vs. 11.0 months; over-4-cycles group median PFS 52.6 months (40.3-64.9); p < 0.001]. Nowadays chemoimmunotherapy with BR is reserved to fit elderly CLL patients, and there are many chemo-free treatment options available; therefore, discontinuation after 4 cycles may be permissible in patients who obtained a CR in order to limit toxicity as much as possible.
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Affiliation(s)
- Francesco Autore
- Dipartimento di Diagnostica per Immagini, Hematology Unit, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Fresa
- Institute of Hematology, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Hematology Unit, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Ilaria Del Principe
- Department of Biomedicine and Prevention, Hematology Unit, University tor Vergata of Rome, Rome, Italy
| | - Raffaele Maglione
- Department of Cellular Biotechnologies and Hematology, Hematology Unit, Sapienza University, Rome, Italy
| | | | - Sabrina Pelliccia
- Hematology Unit, Azienda Ospedaliera-Universitaria Sant'Andrea, Rome, Italy
| | - Azzurra Romeo
- Hematology Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Giuseppe Cimino
- Hematology Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Elena Papa
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Laura De Padua
- Hematology Unit, Fabrizio Spaziani Hospital, Frosinone, Italy
| | | | - Andrea Mengarelli
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Agostino Tafuri
- Hematology Unit, Azienda Ospedaliera-Universitaria Sant'Andrea, Rome, Italy
| | - Concetta Ditto
- Division of Hematology, Ospedale Belcolle, Viterbo, Italy
| | - Francesca Romana Mauro
- Department of Cellular Biotechnologies and Hematology, Hematology Unit, Sapienza University, Rome, Italy
| | - Giovanni Del Poeta
- Department of Biomedicine and Prevention, Hematology Unit, University tor Vergata of Rome, Rome, Italy
| | - Luca Laurenti
- Dipartimento di Diagnostica per Immagini, Hematology Unit, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Hematology, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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Maher N, Mouhssine S, Matti BF, Alwan AF, Gaidano G. Treatment Refractoriness in Chronic Lymphocytic Leukemia: Old and New Molecular Biomarkers. Int J Mol Sci 2023; 24:10374. [PMID: 37373521 DOI: 10.3390/ijms241210374] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults. Despite its indolent clinical course, therapy refractoriness and disease progression still represent an unmet clinical need. Before the advent of pathway inhibitors, chemoimmunotherapy (CIT) was the commonest option for CLL treatment and is still widely used in areas with limited access to pathway inhibitors. Several biomarkers of refractoriness to CIT have been highlighted, including the unmutated status of immunoglobulin heavy chain variable genes and genetic lesions of TP53, BIRC3 and NOTCH1. In order to overcome resistance to CIT, targeted pathway inhibitors have become the standard of care for the treatment of CLL, with practice-changing results obtained through the inhibitors of Bruton tyrosine kinase (BTK) and BCL2. However, several acquired genetic lesions causing resistance to covalent and noncovalent BTK inhibitors have been reported, including point mutations of both BTK (e.g., C481S and L528W) and PLCG2 (e.g., R665W). Multiple mechanisms are involved in resistance to the BCL2 inhibitor venetoclax, including point mutations that impair drug binding, the upregulation of BCL2-related anti-apoptotic family members, and microenvironmental alterations. Recently, immune checkpoint inhibitors and CAR-T cells have been tested for CLL treatment, obtaining conflicting results. Potential refractoriness biomarkers to immunotherapy were identified, including abnormal levels of circulating IL-10 and IL-6 and the reduced presence of CD27+CD45RO- CD8+ T cells.
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Affiliation(s)
- Nawar Maher
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Samir Mouhssine
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Bassam Francis Matti
- Department of Hematology and Bone Marrow Transplant, Hematology and Bone Marrow Transplant Center, Baghdad 00964, Iraq
| | - Alaa Fadhil Alwan
- Department of Clinical Hematology, The National Center of Hematology, Mustansiriyah University, Baghdad 10015, Iraq
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
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Nguyen TT, Nhu NT, Tran VK, Viet-Nhi NK, Ho XD, Jhan MK, Chen YP, Lin CF. Efficacy and safety of add-on anti-CD20 monoclonal antibody to Bruton tyrosine kinase inhibitor treatment for chronic lymphocytic leukemia: a meta-analysis. Sci Rep 2023; 13:9775. [PMID: 37328530 PMCID: PMC10276018 DOI: 10.1038/s41598-023-36279-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
The efficacy of Bruton tyrosine kinase inhibitors (BTKi) remains suboptimal in chronic lymphocytic leukemia (CLL) treatment. A systematic review and meta-analysis were conducted to compare the outcomes of combining anti-CD20 monoclonal antibodies (mAb) with BTKi therapy versus BTKi monotherapy for patients with CLL. We searched for relevant studies in the Pubmed, Medline, Embase, and Cochrane databases until December 2022. We estimated the effective results using a hazard ratio (HR) for survival outcomes and relative risk (RR) for response outcomes and safety. Four randomized controlled trials (including 1056 patients) were found until November 2022 and fulfilled the inclusion criteria. Progression-free survival was significantly improved with the addition of anti-CD20 mAb to BTKi over BTKi (HR 0.70, 95% confidence interval (CI) 0.51-0.97), whereas pooled analysis of overall survival did not favor combination therapy compared to BTKi monotherapy (HR 0.72, 95% CI 0.50-1.04). Combination therapy was related to a statistically better complete response (RR, 2.03; 95% CI 1.01 to 4.06) and an undetectable minimal residual disease rate (RR, 6.43; 95% CI 3.54 to 11.67). The risk of grade ≥ 3 adverse events was comparable between the two groups (RR, 1.08; (95% CI 0.80 to 1.45). Overall, adding anti-CD20 mAb to BTKi revealed superior efficacy than BTKi alone in untreated or previously treated CLL patients without affecting the safety of single-agent BTKi. Conducting further randomized studies to confirm our results and determine the optimal therapy for managing patients with CLL is essential.
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Affiliation(s)
- Thi Thuy Nguyen
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Department of Oncology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Nguyen Thanh Nhu
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Van Khoi Tran
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Nguyen-Kieu Viet-Nhi
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Xuan Dung Ho
- Department of Oncology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Ming-Kai Jhan
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, No. 25, Wuxing St, Xinyi District, Taipei, 110, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Chiou-Feng Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, No. 25, Wuxing St, Xinyi District, Taipei, 110, Taiwan.
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan.
- Core Laboratory of Immune Monitoring, Office of Research & Development, Taipei Medical University, Taipei, 110, Taiwan.
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Gogia A, Gupta R, Sharma A, kumar L, rani L, Mallick S. Safety and Efficacy of Bendamustine and Rituximab (BR) Regimen in Indian Chronic Lymphocytic Leukaemia Patients. Indian J Hematol Blood Transfus 2023; 39:33-39. [PMID: 36699426 PMCID: PMC9868021 DOI: 10.1007/s12288-022-01544-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/19/2022] [Indexed: 01/28/2023] Open
Abstract
We investigated the safety and efficacy of bendamustine-rituximab (BR) in previously untreated symptomatic and advanced CLL patients, as there is no data available on BR from the Indian subcontinent.This retrospective study included 120 consecutive treatment naïve patients with CLL without del (17p), who were registered at the Department of Medical Oncology, AIIMS between January 2010 and July 2018. Bendamustine was given at a dose of 90 mg/m2 on days 1 and 2, combined with rituximab 375 mg/m2 rituximab on day 1, every 28 days for up to 6 courses. Event-free survival (EFS) was defined as the date of treatment to date of relapse, disease progression, or death due to any cause.The median age was 57 years (range: 30-75 years). As per the clinical Rai stage, 30 (25%) patients were in stage II, 42 (35%) were in stage III and 48 (40%) were in stage IV. ZAP70 was positive (> 20%) in 50%, CD 38 was positive (> 30%) in 33%, and CD49d was positive (> 30%) in 49% of cases. Beta-2 microglobulin (B2M) was elevated (≥ 3.5 mg/L) in 80% of cases. Fifty-five cases (50%, n = 110) were IGHV mutated. The mean number of cycles was 5 (1-6). The overall response rate (ORR) seen with BR was 90% and complete response was 45%. Median progression-free survival was 24 months with a median follow-up period of 29 months. Haemoglobin (< 10 g/dL), elevated B2 M, unmutated IGHV had a statistically significant adverse impact on EFS on univariate analysis but on multivariate analysis, only IGHV mutation status was found to had significance on EFS. The median EFS was 27 months in IGHV mutated versus 18 months in IGHV unmutated-CLL patients (p = 0.001). Grade 3/4 neutropenia, thrombocytopenia, anemia, and infections were observed in 30.6%, 8%, and 12% respectively. The most common non-hematological toxicity was skin rash which was grade 1/2 in 24 (20%) cases and grade 3/4 in 12 (10%) cases. This is the largest study from India to demonstrate the safety and efficacy of BR in symptomatic CLL patients. BR is an effective and safe regimen in the first-line treatment of CLL. Unmutated-CLL patients have inferior EFS than mutated-CLL patients. Skin toxicity was the most common adverse effect seen in our population which was observed in around one-third of cases.
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Affiliation(s)
- Ajay Gogia
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Ritu Gupta
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Lalit kumar
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Lata rani
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Saumyaranjan Mallick
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Effectiveness and Safety of Ibrutinib for Chronic Lymphocytic Leukemia in Routine Clinical Practice: 3-Year Follow-up of the Belgian Ibrutinib Real-World Data (BiRD) Study. Clin Hematol Int 2022; 4:133-143. [PMID: 36227519 PMCID: PMC9763520 DOI: 10.1007/s44228-022-00020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/16/2022] [Indexed: 11/07/2022] Open
Abstract
The multicenter observational BiRD study investigated the real-world effectiveness and safety of ibrutinib in patients with chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL) and Waldenström's macroglobulinemia (WM) in Belgium. This interim analysis reports results for patients with CLL, with a median follow-up of 34 months. Overall, patients had predominantly relapsed/refractory disease (73%) and were elderly (median age 72 years) with high-risk features such as del17p and/or TP53 mutations (59%). Patients were included either prospectively or retrospectively, and the total patient population effectiveness results were adjusted with left truncation. In the effectiveness population (N = 221: prospective, n = 71; retrospective, n = 150), the overall response rate was 90.0%. Median progression-free survival was 38.3 months (prospective, not estimable; retrospective, 51.5 months) and median overall survival was not yet estimable in the total, prospective and retrospective groups. Treatment-emergent adverse events (TEAEs) for the prospective and retrospective groups are reported separately. Any-grade TEAEs of interest in the prospective/retrospective groups included infections (67.1%/60.1%), diarrhea (20.5%/10.5%), hypertension (16.4%/9.8%) and atrial fibrillation (12.3%/7.2%). Major bleeding was reported in 5.5%/3.3% of prospective/retrospective patients, with little difference observed between those receiving versus not receiving antithrombotic treatment. Discontinuations due to toxicity were reported in 10.5% of patients. Results from this interim analysis show treatment with ibrutinib to be effective and tolerable, with no new safety signals observed. Future analyses will report on longer-term follow-up.
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Relative dose intensity of obinutuzumab-chlorambucil in chronic lymphocytic leukemia: a multicenter Italian study. Blood Adv 2022; 6:3875-3878. [PMID: 35789375 PMCID: PMC9278285 DOI: 10.1182/bloodadvances.2022006964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022] Open
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Treatment Options for Elderly/Unfit Patients with Chronic Lymphocytic Leukemia in the Era of Targeted Drugs: A Comprehensive Review. J Clin Med 2021; 10:jcm10215104. [PMID: 34768624 PMCID: PMC8584288 DOI: 10.3390/jcm10215104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) incidence increases with age reaching 37.9/100,000 in patients over 85 years. Although there is no standardized geriatric tool specifically validated for CLL, a correct framing of the fitness status is of critical importance to individualize treatment strategies. Based on the evidence available to date, frontline chemoimmunotherapy has an increasingly narrowing application, being eligible for candidacy only in elderly fit patients without or with minimal geriatric syndromes. On the other hand, treatment with BCR inhibitors, monotherapy, or in combination with anti-CD20 antibodies (e.g., obinutuzumab), must be preferred both for frontline and relapsed CLL not only in unfit patients, but also in fit patients with unmutated IGHV or harboring del(17p) and/or TP53 mutations/deletions. Second-generation inhibitors (e.g., acalabrutinib, zanubrutinib, pirtobrutinib) are novel compounds that, due to their better safety profile and different specificity, will help physicians overcome some of the safety issues and treatment resistances. In the era of targeted therapies, treatment decisions in elderly and/or unfit patients with CLL must be a balance between efficacy and safety, carefully evaluating comorbidities and geriatric syndromes to ensure the best approach to improve both quality of life and life expectancy.
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Alshemmari SH, Hamdah A, Pandita R, Kunhikrishnan A. Chronic lymphocytic leukemia in a young population. Leuk Res 2021; 110:106668. [PMID: 34492597 DOI: 10.1016/j.leukres.2021.106668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) is uncommon in the Middle East. There is limited data on the prognosis and of CLL in this region. METHODS This was a retrospective study (2009-2020) of consecutively diagnosed patients with CLL at Kuwait Cancer Center. The diagnosis, prognosis, treatment indication, response criteria, and adverse events were recorded per International Workshop on Chronic Lymphocytic Leukemia guidelines. RESULTS A total of 219 patients with CLL were enrolled in the study. The crude annual incidence is 0.4 per 100,000. The median follow-up was 120 months. The median age at diagnosis was 59 years, and 32 % of patients with CLL were ≤ 55 years of age. Prognostic fluorescence in situ hybridization data were available in 213 cases. del (13q14/13q34) was found in 80 (31 %) cases, del (11q) in 23 (10.7 %) cases, del (17p) in 11 (5.16 %) cases, and trisomy 12 in 46 (21.5 %) cases. IGHV mutation status was available in 92 cases, 45 of which (48.9) were mutated and 47 (51.1 %) of which were not. The median progression-free survival (PFS) for the entire cohort was 178 months [95 % CI: 145-NE].· The median OS was 203 months [95 % CI: 145-NE]. The median PFS for the IGHV mutated cases was not reached [95 % CI: 178 - NE]; while the median PFS for the unmutated CLL cases was 24 months [95 % CI: 124 - NE]. CONCLUSION CLL is a rare hematological malignancy in the Middle East. Our CLL cohort is younger and expresses less del13q, but has similar rates of IGHV mutations.
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Affiliation(s)
- Salem H Alshemmari
- Department of Medicine, Faculty of Medicine, Kuwait; Department of Hematology, Kuwait Cancer Center, Kuwait.
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Cost-effectiveness of first-line vs third-line ibrutinib in patients with untreated chronic lymphocytic leukemia. Blood 2021; 136:1946-1955. [PMID: 32518952 DOI: 10.1182/blood.2020004922] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/03/2020] [Indexed: 01/18/2023] Open
Abstract
The ALLIANCE A041202 trial found that continuously administered ibrutinib in the first-line setting significantly prolonged progression-free survival compared with a fixed-duration treatment of rituximab and bendamustine in older adults with chronic lymphocytic leukemia (CLL). In this study, we created a Markov model to assess the cost-effectiveness of ibrutinib in the first-line setting, compared with a strategy of using ibrutinib in the third-line after failure of time-limited bendamustine and venetoclax-based regimens. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct health care costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated from a US payer perspective. First-line ibrutinib was associated with an improvement of 0.26 QALYs and 0.40 life-years compared with using ibrutinib in the third-line setting. However, using ibrutinib in the first-line led to significantly higher health care costs (incremental cost of $612 700), resulting in an ICER of $2 350 041 per QALY. The monthly cost of ibrutinib would need to be decreased by 72% for first-line ibrutinib therapy to be cost-effective at a willingness-to-pay threshold of $150 000 per QALY. In a scenario analysis where ibrutinib was used in the second-line in the delayed ibrutinib arm, first-line ibrutinib had an incremental cost of $478 823, an incremental effectiveness of 0.05 QALYs, and an ICER of $9 810 360 per QALY when compared with second-line use. These data suggest that first-line ibrutinib for unselected older adults with CLL is unlikely to be cost-effective under current pricing. Delaying ibrutinib for most patients with CLL until later lines of therapy may be a reasonable strategy to limit health care costs without compromising clinical outcomes.
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Mattsson A, Sylvan SE, Asklid A, Wiggh J, Winqvist M, Lundin J, Mansouri L, Rosenquist R, Johansson H, Österborg A, Hansson L. Risk-adapted bendamustine + rituximab is a tolerable treatment alternative for elderly patients with chronic lymphocytic leukaemia: a regional real-world report on 141 consecutive Swedish patients. Br J Haematol 2020; 191:426-432. [PMID: 32779190 PMCID: PMC7689859 DOI: 10.1111/bjh.17032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 11/26/2022]
Abstract
Bendamustine + rituximab (BR) is the current first-line standard-of-care for chronic lymphocytic leukaemia (CLL) in fit patients aged 66-70 years, whereas chlorambucil + CD20 antibody is recommended in older patients with co-morbidities. This retrospective real-world study investigated whether risk-adapted BR was safe and effective in elderly patients. All 141 CLL patients in the Stockholm region (diagnosed from 2007 to 2016, identified from regional registries) who had received BR as first (n = 84) or later line (n = 57) were analysed. Median age was 72 years, 49% had Binet stage C, 40% had Cumulative Illness Rating Scale (CIRS) score ≥ 6, 20% Eastern Cooperative Oncology Group (ECOG) score 2. None had del(17p). Only 15% of patients aged ≥80 years received full-dose bendamustine and 65% of them postponed rituximab until cycle 2. Corresponding numbers in patients 73-79 years were 21% and 36% and in <73 years, 63% and 33%. Overall response rate was 83% (first line) and 67% (later line) (P < 0·022) equally distributed between age subsets. ECOG, immunoglobulin heavy chain variable region (IGHV) mutational status and cytogenetics, but not treatment line and age, were significant factors on progression-free survival (PFS) in multivariate analysis. Infections and neutropenia/thrombocytopenia (≥grade 3) were similar across age subgroups. In summary, BR was well tolerated even in patients ≥80 years, with similar efficacy and safety as in less old patients, provided that carefully adapted dosing was applied.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride/administration & dosage
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Prognosis
- Retrospective Studies
- Rituximab/administration & dosage
- Sweden/epidemiology
- Treatment Outcome
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Affiliation(s)
- Agnes Mattsson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of Internal MedicineSödersjukhusetStockholmSweden
| | - Sandra E. Sylvan
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
| | - Anna Asklid
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of OncologyKarolinska University HospitalStockholmSweden
| | - Joel Wiggh
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Maria Winqvist
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Jeanette Lundin
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Larry Mansouri
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Richard Rosenquist
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Hemming Johansson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
| | - Anders Österborg
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Lotta Hansson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
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12
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Cuneo A, Mato AR, Rigolin GM, Piciocchi A, Gentile M, Laurenti L, Allan JN, Pagel JM, Brander DM, Hill BT, Winter A, Lamanna N, Tam CS, Jacobs R, Lansigan F, Barr PM, Shadman M, Skarbnik AP, Pu JJ, Sehgal AR, Schuster SJ, Shah NN, Ujjani CS, Roeker L, Orlandi EM, Billio A, Trentin L, Spacek M, Marchetti M, Tedeschi A, Ilariucci F, Gaidano G, Doubek M, Farina L, Molica S, Di Raimondo F, Coscia M, Mauro FR, de la Serna J, Medina Perez A, Ferrarini I, Cimino G, Cavallari M, Cucci R, Vignetti M, Foà R, Ghia P. Efficacy of bendamustine and rituximab in unfit patients with previously untreated chronic lymphocytic leukemia. Indirect comparison with ibrutinib in a real-world setting. A GIMEMA-ERIC and US study. Cancer Med 2020; 9:8468-8479. [PMID: 32969597 PMCID: PMC7666748 DOI: 10.1002/cam4.3470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 12/29/2022] Open
Abstract
Limited information is available on the efficacy of front‐line bendamustine and rituximab (BR) in chronic lymphocytic leukemia (CLL) with reduced renal function or coexisting conditions. We therefore analyzed a cohort of real‐world patients and performed a matched adjusted indirect comparison with a cohort of patients treated with ibrutinib. One hundred and fifty‐seven patients with creatinine clearance (CrCl) <70 mL/min and/or CIRS score >6 were treated with BR. The median age was 72 years; 69% of patients had ≥2 comorbidities and the median CrCl was 59.8 mL/min. 17.6% of patients carried TP53 disruption. The median progression‐free survival (PFS) was 45 months; TP53 disruption was associated with a shorter PFS (P = 0.05). The overall survival (OS) at 12, 24, and 36 months was 96.2%, 90.1%, and 79.5%, respectively. TP53 disruption was associated with an increased risk of death (P = 0.01). Data on 162 patients ≥65 years treated with ibrutinib were analyzed and compared with 165 patients ≥65 years treated with BR. Factors predicting for a longer PFS at multivariable analysis in the total patient population treated with BR and ibrutinib were age (HR 1.06, 95% CI 1.02‐1.10, P < 0.01) and treatment with ibrutinib (HR 0.55, 95% CI 0.33‐0.93, P = 0.03). In a post hoc analysis of patients in advanced stage, a significant PFS advantage was observed in patient who had received ibrutinib (P = 0.03), who showed a trend for OS advantage (P = 0.08). We arrived at the following conclusions: (a) BR is a relatively effective first‐line regimen in a real‐world population of unfit patients without TP53 disruption, (b) ibrutinib provided longer disease control than BR in patients with advanced disease stage.
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Affiliation(s)
- Antonio Cuneo
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Anthony R Mato
- Division of Hematological Oncology, CLL Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gian Matteo Rigolin
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Alfonso Piciocchi
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Massimo Gentile
- Department of Onco-Hematology, Hematology Unit, A.O. of Cosenza, Cosenza, Italy
| | - Luca Laurenti
- Department of Radiological, Radiotherapeutic and Hematological Sciences, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA, USA
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Brian T Hill
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allison Winter
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Constantine S Tam
- Peter McCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Ryan Jacobs
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | | | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Alan P Skarbnik
- Lymphoproliferative Disorders Program, Novant Health Cancer Institute, Charlotte, NC, USA
| | - Jeffrey J Pu
- SUNY Upstate Medical University, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Stephen J Schuster
- Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nirav N Shah
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chaitra S Ujjani
- Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Lindsey Roeker
- Division of Hematological Oncology, CLL Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Atto Billio
- Hematology and Transplant Unit, San Maurizio Hospital, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology, Department of Medicine, University of Padua, Padua, Italy
| | - Martin Spacek
- Department of Medicine, Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Alessandra Tedeschi
- Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of eastern Piedmont, Novara, Italy
| | - Michael Doubek
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lucia Farina
- Hematology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Stefano Molica
- Hematology Unit, A. Pugliese Hospital, Azienda Ospedaliera Pugliese Ciaccio, Catanzaro, Italy
| | | | - Marta Coscia
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | | | | | - Isacco Ferrarini
- Hematology, Department of Cell Therapy and Hematology, University Hospital, Verona, Italy
| | - Giuseppe Cimino
- Department of Translational and Precision Medicine, University "La Sapienza", UOC di Ematologia con Trapianto, Ospedale S. Maria Goretti, Latina, Italy
| | - Maurizio Cavallari
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Rosalba Cucci
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Marco Vignetti
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Paolo Ghia
- Strategic Research Program on CLL, Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
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13
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Nagl L, Koinig K, Hofer F, Stauder R. Comorbidities cluster with impaired functional capacities and depressive mood and predict adverse outcome in older patients with hematological malignancies. Leuk Lymphoma 2020; 61:1954-1964. [PMID: 32281446 DOI: 10.1080/10428194.2020.1747063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study evaluates prevalence of comorbidities and their association with impairments in older patients with hematological malignancies at initial diagnosis (n = 209). At least one comorbidity was present in 62.2%, 68.5% and 93.8% as defined by CCI (Charlson Comorbidity Index), Cumulative Illness Rating Scale-Geriatric (CIRS-G) and HCT-Comorbidity Index, respectively. Severe comorbidities (CIRS-G Grade 3/4) were present in 57.9%. The mean number of affected organ systems was 3.6 (CIRS-G categories), with diabetes (18.2%), congestive heart failure and prior solid tumors (each 17.7%) detected most frequently. Comorbidities were significantly correlated with reduced functional and objective physical capacities, impaired performance and depressive mood. Both CCI and CIRS-G were found to be prognostic factors for OS (p < 0.05). CCI scoring of comorbidities, diagnosis MDS/AML and a body mass index <23kg/m2 were independent adverse predictors for OS. This first prospective analysis reveals a prognostic significance of comorbidities. Clustering of comorbidities with impairments suggests common mechanisms.
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Affiliation(s)
- Laurenz Nagl
- Department of Internal Medicine V (Haematology and Oncology), Medical University of Innsbruck, Innsbruck, Austria
| | - Karin Koinig
- Department of Internal Medicine V (Haematology and Oncology), Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Hofer
- Department of Internal Medicine V (Haematology and Oncology), Medical University of Innsbruck, Innsbruck, Austria
| | - Reinhard Stauder
- Department of Internal Medicine V (Haematology and Oncology), Medical University of Innsbruck, Innsbruck, Austria
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14
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Kabadi SM, Goyal RK, Nagar SP, Kaye JA, Davis KL. Treatment patterns, adverse events, and economic burden in a privately insured population of patients with chronic lymphocytic leukemia in the United States. Cancer Med 2019; 8:3803-3810. [PMID: 31144473 PMCID: PMC6639180 DOI: 10.1002/cam4.2268] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Contemporary data describing treatment patterns, adverse events (AEs), and outcomes in patients with chronic lymphocytic leukemia (CLL) in clinical practice are lacking. We conducted a retrospective cohort study and assessed treatment patterns, AEs, health-care resource use (HCRU), and costs in patients with diagnosis of CLL. METHODS Using a nationally representative population of privately insured patients in the US, adult patients with CLL diagnosis (July 2012-June 2015) were selected if they had continuous health plan enrollment for ≥12 months before the first CLL diagnosis without any evidence of any CLL-directed treatment. Treatment patterns up to four lines of therapy (LOT) and occurrence of AEs during CLL therapies were assessed. Mean per-patient monthly HCRU and costs were assessed overall and by number of unique AEs. RESULTS Of all patients meeting the selection criteria (n = 7,639; median age, 66 years), 18% (n = 1,379) received a systemic therapy during study follow-up. Of these, bendamustine/rituximab (BR) was the most common first observed regimen (28.1%), while ibrutinib was the most common therapy in the second (20.8%) and third (25.5%) observed regimens. The mean monthly all-cause and CLL-related costs, among patients treated with a systemic therapy, were $7,943 (SD = $15,757) and $5,185 (SD = $9,935), respectively. Mean monthly all-cause costs increased by the number of AEs (from $905 [SD = $1,865] among those with no AEs to $6,032 [SD = $13,290] among those with ≥6 AEs). CONCLUSIONS Chemoimmunotherapy, particularly BR, was the most common first observed therapy for CLL, whereas ibrutinib was most preferred in the second and third observed lines of therapy during the study period. Findings demonstrate that the economic burden of AEs in CLL is substantial.
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Affiliation(s)
| | - Ravi K Goyal
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Saurabh P Nagar
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | - Keith L Davis
- RTI Health Solutions, Research Triangle Park, North Carolina
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15
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Prospective observational study in comorbid patients with chronic lymphocytic leukemia receiving first-line bendamustine with rituximab. Leuk Res 2019; 79:17-21. [DOI: 10.1016/j.leukres.2019.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/21/2022]
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16
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Visentin A, Facco M, Gurrieri C, Pagnin E, Martini V, Imbergamo S, Frezzato F, Trimarco V, Severin F, Raggi F, Scomazzon E, Pravato S, Piazza F, Semenzato G, Trentin L. Prognostic and Predictive Effect of IGHV Mutational Status and Load in Chronic Lymphocytic Leukemia: Focus on FCR and BR Treatments. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:678-685.e4. [PMID: 31371221 DOI: 10.1016/j.clml.2019.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/12/2019] [Accepted: 03/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most important markers in chronic lymphocytic leukemia (CLL) are TP53 abnormalities, including mutations and deletions, and the mutational status of immunoglobulin heavy chain (IGHV) genes. However, some recent publications suggest that the IGHV mutational load could have a prognostic effect on CLL patients. PATIENTS AND METHODS We performed a single-center retrospective study on 459 patients with productive rearrangement of the B-cell receptor to evaluate the prognostic and predictive role of IGHV mutational status and burden within the germline sequence. In particular we focused on FCR (fludarabine with cyclophosphamide, and rituximab)- (64 naive and 30 relapsed) and BR (bendamustine with rituximab)-treated patients (17 naive and 61 relapsed). A cutoff value of 2% of difference within the IGHV germline was used to define the IGHV mutational status. RESULTS We reported that unmutated IGHV (U-IGHV) patients were characterized by a significant shorter progression-free survival (PFS) and overall survival (P < .0001) compared with mutated IGHV (M-IGHV) patients. Moreover, treatment-naive M-IGHV patients experienced a long-term disease control after FCR or BR, with PFS reaching a plateau regardless of mutational load. In our series the extent of IGHV gene mutation did not provide further relevant prognostic data over the mutational status. Relapsed patients showed dismal outcome with chemoimmunotherapy regardless of IGHV status or load. CONCLUSION Our data, together with from those from the literature, confirmed the cutoff value of 2% to define the mutational status of IGHV gene and suggest that FCR/BR are good first-line treatment strategies for M-IGHV patients, whereas U-IGHV patients should be managed with B-cell receptor and/or B-cell lymphoma 2 (BCL2) inhibitors.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Monica Facco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Carmela Gurrieri
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Elisa Pagnin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Veronica Martini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Silvia Imbergamo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Federica Frezzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Valentina Trimarco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Filippo Severin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Flavia Raggi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Edoardo Scomazzon
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Gianpietro Semenzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Padua, Italy.
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17
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Samples LS, Graf SA. On the front line: first choice pharmacotherapeutics for chronic lymphocytic leukemia. Expert Opin Pharmacother 2018; 19:1675-1684. [PMID: 30222470 DOI: 10.1080/14656566.2018.1524874] [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: 10/28/2022]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy with a highly variable clinical course. Frontline treatments include cytotoxic chemotherapies, immunotherapies, and small molecule inhibitors. Clinical and molecular factors guide treatment initiation and selection. Over the last decade, refinement of CLL risk stratification tools and growth of the arsenal of effective therapeutics have profoundly improved outcomes. These advances have concurrently increased the complexity of managing the early phases of treatment. AREAS COVERED This review describes the factors considered in the determination of first-line treatment of CLL. Areas of emphasis include assessment of patient fitness, disease classification and risk stratification, and the mechanisms, efficacy, and toxicities associated with available pharmacotherapeutics. EXPERT OPINION Multiple different treatments may be appropriate for a specific clinical scenario, and selection among them requires discussion of relative risks and benefits. Advances in frontline CLL treatment will continue to shift the treatment paradigm toward prioritizing quality of life alongside survival, limiting treatment and toxicity, and the development of biologically rational synergistic drug combinations and sequences.
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Affiliation(s)
- Laura S Samples
- a Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA
| | - Solomon A Graf
- a Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA.,b Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,c Department of Hematology and Oncology , Veterans Affairs Puget Sound Health Care System , Seattle , WA , USA
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18
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Gentile M, Shanafelt TD, Mauro FR, Reda G, Rossi D, Laurenti L, Del Principe MI, Cutrona G, Angeletti I, Coscia M, Herishanu Y, Chiarenza A, Molica S, Ciolli S, Goldschmidt N, Angrilli F, Giordano A, Rago A, Bairey O, Tripepi G, Chaffee KG, Sameer PA, Vigna E, Zirlik K, Shvidel L, Innocenti I, Recchia AG, Di Raimondo F, Del Poeta G, Cortelezzi A, Neri A, Ferrarini M, Gaidano G, Kay NE, Polliack A, Foà R, Morabito F. Predictive value of the CLL-IPI in CLL patients receiving chemo-immunotherapy as first-line treatment. Eur J Haematol 2018; 101:703-706. [PMID: 30039576 DOI: 10.1111/ejh.13149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Tait D Shanafelt
- Department of Medicine, Division of Hematology, Stanford University, Stanford, California
| | | | - Gianluigi Reda
- Unità di Ematologia, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - Davide Rossi
- Oncology Institute of Southern Switzerland, Institute of Oncology Research, Bellinzona, Switzerland
| | - Luca Laurenti
- Dipartimento di Ematologia, Università Cattolica "A. Gemelli" Rome, Rome, Italy
| | - Maria Ilaria Del Principe
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli Studi di Roma "Tor Vergata," Rome, Rome, Italy
| | | | - Ilaria Angeletti
- Reparto di Oncoematologia Azienda Ospedaliera Santa Maria di Terni, Terni, Italy
| | - Marta Coscia
- Divisione di Ematologia, Università di Torino, A.O. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Yair Herishanu
- Department of Hematology, Tel-Aviv Sourasky Medical and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Annalisa Chiarenza
- Divisione di Ematologia, Ospedale Ferrarotto, Università di Catania, Catania, Italy
| | - Stefano Molica
- Dipartimento di Onco-ematologia, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | | | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Annamaria Giordano
- Ematologia-Azienda Ospedaliero-Universitaria, Policlinico consorziale di Bari, Bari, Italy
| | - Angela Rago
- UOC Ematologia Ospedale Santa Maria Goretti, Latina, Italy
| | - Osnat Bairey
- Department of Hematology, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Giovanni Tripepi
- Consiglio Nazionale delle Ricerche, Istituto di Biomedicina ed Immunologia Molecolare, Reggio Calabria, Italy
| | - Kari G Chaffee
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Parikh A Sameer
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Katja Zirlik
- Department of Haematology and Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | - Lev Shvidel
- Department of Hematology Kaplan Medical Center, Rehovot and Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Idanna Innocenti
- Dipartimento di Ematologia, Università Cattolica "A. Gemelli" Rome, Rome, Italy
| | - Anna Grazia Recchia
- Unità di Ricerca Biotecnologica, Azienda Sanitaria Provinciale di Cosenza, Aprigliano (CS), Italy
| | | | - Giovanni Del Poeta
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli Studi di Roma "Tor Vergata," Rome, Rome, Italy
| | - Agostino Cortelezzi
- Unità di Ematologia, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | - Antonino Neri
- Unità di Ematologia, Fondazione Ca' Granda IRCCS, Ospedale Maggiore Policlinico, Università di Milano, Milan, Italy
| | | | - Gianluca Gaidano
- Division of Haematology, Department of Translational Medicine, UPO, Novara, Italy
| | - Neil E Kay
- Department of Medicine, Division of Hematology, Stanford University, Stanford, California
| | - Aaron Polliack
- Department of Hematology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Robin Foà
- Ematologia, Università Sapienza, Roma, Italy
| | - Fortunato Morabito
- Unità di Ricerca Biotecnologica, Azienda Sanitaria Provinciale di Cosenza, Aprigliano (CS), Italy
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19
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Validation of a biological score to predict response in chronic lymphocytic leukemia patients treated front-line with bendamustine and rituximab. Leukemia 2018; 32:1869-1873. [PMID: 29588545 DOI: 10.1038/s41375-018-0100-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/31/2018] [Accepted: 02/07/2018] [Indexed: 11/08/2022]
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20
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Van Sanden S, Baculea S, Diels J, Cote S. Comparative Efficacy of Ibrutinib Versus Obinutuzumab + Chlorambucil in First-Line Treatment of Chronic Lymphocytic Leukemia: A Matching-Adjusted Indirect Comparison. Adv Ther 2017; 34:1650-1661. [PMID: 28573505 PMCID: PMC5504213 DOI: 10.1007/s12325-017-0564-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Ibrutinib (ibr) monotherapy and the combination of obinutuzumab plus chlorambucil (obi) are approved for previously untreated chronic lymphocytic leukemia (CLL). No trials directly comparing their efficacy are available. Therefore a matching-adjusted indirect comparison (MAIC) was performed to provide insight into their relative efficacy in terms of progression-free survival (PFS) and overall survival (OS). MAIC attempts to adjust for between-trial differences in factors known or suspected to influence treatment effects, to minimize bias. METHODS A MAIC within a Bayesian framework was conducted using individual patient data from the RESONATE-2 study of ibr versus chlorambucil and published data from the CLL11 study of obi versus chlorambucil. Both studies were conducted in patients ineligible for full-dose fludarabine-based therapy. After matching, the reweighted adjusted relative efficacy measure of ibr versus chlorambucil from RESONATE-2 [hazard ratio (HR), 95% credible interval (CrI)] was compared with that of obi versus chlorambucil from CLL11 for each endpoint, using a Bayesian indirect comparison. RESULTS Our results suggest that in a population with similar average baseline characteristics to CLL11, ibr would improve PFS and OS outcomes compared to obi. Before matching, the HRs for ibr versus obi were 0.48 [CrI = 0.22-1.02, p(HR <1) = 97%], 0.85 [CrI = 0.44-1.63, p(HR <1) = 69%], and 0.40 [CrI = 0.10-1.54, p(HR <1) = 91%] for PFS by investigator assessment, PFS by independent review committee, and OS, respectively. After matching on all available characteristics the HRs decreased to 0.12 [CrI = 0.02-0.97, p(HR <1) = 98%], 0.24 [CrI = 0.04-1.35, p(HR <1) = 95%], and 0.21 [CrI = <0.01-8.89, p(HR <1) = 79%], respectively. There was a large variance around the treatment effect for OS due to the low number of deaths. CONCLUSION Our analysis suggests that ibrutinib is highly likely to provide greater PFS benefit than obinutuzumab plus chlorambucil in older or less fit patients with previously untreated CLL. There is also an indication of improvement in OS, albeit with a higher uncertainty due to the low number of events. FUNDING Janssen-Cilag Ltd.
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Affiliation(s)
| | | | | | - Sarah Cote
- Janssen-Cilag, High Wycombe, Buckinghamshire, UK
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21
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Giudice V, Rosamilio R, Serio B, Di Crescenzo RM, Rossi F, De Paulis A, Pilone V, Selleri C. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia. Open Med (Wars) 2017; 11:361-368. [PMID: 28352821 PMCID: PMC5329853 DOI: 10.1515/med-2016-0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/19/2016] [Indexed: 12/17/2022] Open
Abstract
The management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.
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Affiliation(s)
- Valentina Giudice
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Rosa Rosamilio
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Bianca Serio
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | | | - Francesca Rossi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Amato De Paulis
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Vincenzo Pilone
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, Department of Medicine and Surgery, University of Salerno, Salerno, 84131, Italy
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Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG, O'Brien S, Gribben J, Rai K. Chronic lymphocytic leukaemia. Nat Rev Dis Primers 2017; 3:16096. [PMID: 28102226 PMCID: PMC5336551 DOI: 10.1038/nrdp.2016.96] [Citation(s) in RCA: 287] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is a malignancy of CD5+ B cells that is characterized by the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues. Signalling via surface immunoglobulin, which constitutes the major part of the B cell receptor, and several genetic alterations play a part in CLL pathogenesis, in addition to interactions between CLL cells and other cell types, such as stromal cells, T cells and nurse-like cells in the lymph nodes. The clinical progression of CLL is heterogeneous and ranges from patients who require treatment soon after diagnosis to others who do not require therapy for many years, if at all. Several factors, including the immunoglobulin heavy-chain variable region gene (IGHV) mutational status, genomic changes, patient age and the presence of comorbidities, should be considered when defining the optimal management strategies, which include chemotherapy, chemoimmunotherapy and/or drugs targeting B cell receptor signalling or inhibitors of apoptosis, such as BCL-2. Research on the biology of CLL has profoundly enhanced our ability to identify patients who are at higher risk for disease progression and our capacity to treat patients with drugs that selectively target distinctive phenotypic or physiological features of CLL. How these and other advances have shaped our current understanding and treatment of patients with CLL is the subject of this Primer.
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Affiliation(s)
- Thomas J Kipps
- Division of Hematology-Oncology, Department of Medicine, Moores Cancer Centre, University of California, San Diego, 3855 Health Sciences Drive M/C 0820, La Jolla, California 92093, USA
| | - Freda K Stevenson
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Catherine J Wu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlo M Croce
- Department of Molecular Virology, Immunology and Medical Genetics, Ohio State University, Columbus, Ohio, USA
| | - Graham Packham
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - William G Wierda
- Department of Hematology, MD Anderson Cancer Centre, Houston, Texas, USA
| | - Susan O'Brien
- Division of Hematology, Department of Medicine, University of California, Irvine, California, USA
| | - John Gribben
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Kanti Rai
- CLL Research and Treatment Program, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York, USA
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