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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [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] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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2
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Alshemmari SH, Siddiqui MA, Pandita R, Osman HY, Cherif H, O'Brien S, Marashi M, Al Farsi K. Evidence-Based Management of Chronic Lymphocytic Leukemia: Consensus Statements from the Gulf Region. Acta Haematol 2023; 147:260-279. [PMID: 37751733 DOI: 10.1159/000531675] [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] [Received: 09/13/2022] [Accepted: 06/16/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Despite recent advances in diagnosis, prognostication, and treatment options, chronic lymphocytic leukemia (CLL) is still a largely incurable disease. New concepts on diagnosis, staging, treatment, and follow-up on CLL have been incorporated throughout recent years. The lack of regional consensus guidelines has led to varying practices in the management of patients with CLL in the region. This manuscript aims to reach a consensus among expert hematologists regarding the definitions, classifications, and related practices of CLL. The experts developed a set of statements utilizing their personal experience together with the current literature on CLL management. This consensus aims to provide guidance for healthcare professionals involved in the management of CLL and serves as a step in developing regional guidelines. METHODS Eight experts responded to 50 statements regarding the diagnosis, staging, treatment, and prognosis of CLL with three potential answering alternatives ranging between agree, disagree, and abstain. This consensus adopted a modified Delphi consensus methodology. A consensus was reached when at least 75% of the agreement to the answer was reached. This manuscript presents the scientific insights of the participating attendees, panel discussions, and the supporting literature review. RESULTS Of the 50 statements, a consensus was reached on almost all statements. Statements covered CLL-related topics, including diagnostic evaluation, staging, risk assessment, different patient profiles, prognostic evaluation, treatment decisions, therapy sequences, response evaluation, complications, and CLL during the COVID-19 pandemic. CONCLUSION In recent years, CLL management has progressed significantly, with many diagnostic tests and several novel treatments becoming available. This consensus gathers decades of consolidated principles, novel research, and promising prospects for the management of this disease.
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Affiliation(s)
- Salem H Alshemmari
- Department of Medicine, Faculty of Medicine and Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Mustaqeem A Siddiqui
- Hematology and Oncology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- Mayo Clinic Division of Hematology, Rochester, Minnesota, USA
| | - Ramesh Pandita
- Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Hani Y Osman
- Oncology Department, Tawam Hospital, Al Ain, United Arab Emirates
| | - Honar Cherif
- Departmant of Hematology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, USA
| | - Mahmoud Marashi
- Department of Hematology, Dubai Healthcare Authority, Dubai, United Arab Emirates
| | - Khalil Al Farsi
- Department of Hematology, Sultan Qaboos University Hospital Muscat, Seeb, Oman
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3
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Benintende G, Pozzo F, Innocenti I, Autore F, Fresa A, D’Arena G, Gattei V, Lurenti L. Measurable residual disease in chronic lymphocytic leukemia. Front Oncol 2023; 13:1112616. [PMID: 36865804 PMCID: PMC9971803 DOI: 10.3389/fonc.2023.1112616] [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: 11/30/2022] [Accepted: 01/24/2023] [Indexed: 02/16/2023] Open
Abstract
Measurable residual disease (MRD) is defined as the presence of residual cancer cells after treatment in patients with clinically undetectable disease, who would otherwise be considered in complete remission. It is a highly sensitive parameter which indicates the disease burden and predicts survival in this setting of patients. In recent years, MRD has gained a role in many hematological malignancies as a surrogate endpoint for clinical trials: undetectable MRD has been correlated to longer progression free survival (PFS) and overall survival (OS). New drugs and combinations have been developed with the aim to achieve MRD negativity, which would indicate favorable prognosis. Different methods to measure MRD have also been devised, which include flow cytometry, polymerase chain reaction (PCR) and next generation sequencing (NGS), with different sensitivity and accuracy in evaluating deep remission after treatment. In this review, we will analyze the current recommendations for the detection of MRD, with particular focus on its role in Chronic Lymphocytic Leukemia (CLL), as well as the different detection methods. Moreover, we will discuss the results of clinical trials and the role of MRD in new therapeutic schemes with inhibitors and monoclonal antibodies. MRD is not currently used in the clinical practice to evaluate response to treatment, due to technical and economical limitations, but it's gaining more and more interest in trials settings, especially since the introduction of venetoclax. The use of MRD in trials will likely be followed by a broader practical application in the future. The aim of this work is to provide a reader-friendly summary of the state of art in the field, as MRD will soon become an accessible tool to evaluate our patients, predict their survival and guide physician's therapeutic choices and preferences.
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Affiliation(s)
- Giulia Benintende
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy,*Correspondence: Giulia Benintende,
| | - Federico Pozzo
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Giovanni D’Arena
- “San Luca” Hospital, Azienda Sanitaria Locale (ASL) Salerno, Salerno, Italy
| | - Valter Gattei
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Luca Lurenti
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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4
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Schilhabel A, Szczepanowski M, van Gastel-Mol EJ, Schillalies J, Ray J, Kim D, Nováková M, Dombrink I, van der Velden VHJ, Boettcher S, Brüggemann M, Kneba M, van Dongen JJM, Langerak AW, Ritgen M. Patient specific real-time PCR in precision medicine - Validation of IG/TR based MRD assessment in lymphoid leukemia. Front Oncol 2023; 12:1111209. [PMID: 36727082 PMCID: PMC9885152 DOI: 10.3389/fonc.2022.1111209] [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: 11/29/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
Detection of patient- and tumor-specific clonally rearranged immune receptor genes using real-time quantitative (RQ)-PCR is an accepted method in the field of precision medicine for hematologic malignancies. As individual primers are needed for each patient and leukemic clone, establishing performance specifications for the method faces unique challenges. Results for series of diagnostic assays for CLL and ALL patients demonstrate that the analytic performance of the method is not dependent on patients' disease characteristics. The calibration range is linear between 10-1 and 10-5 for 90% of all assays. The detection limit of the current standardized approach is between 1.8 and 4.8 cells among 100,000 leukocytes. RQ-PCR has about 90% overall agreement to flow cytometry and next generation sequencing as orthogonal methods. Accuracy and precision across different labs, and above and below the clinically applied cutoffs for minimal/measurable residual disease (MRD) demonstrate the robustness of the technique. The here reported comprehensive, IVD-guided analytical validation provides evidence that the personalized diagnostic methodology generates robust, reproducible and specific MRD data when standardized protocols for data generation and evaluation are used. Our approach may also serve as a guiding example of how to accomplish analytical validation of personalized in-house diagnostics under the European IVD Regulation.
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Affiliation(s)
- Anke Schilhabel
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany,*Correspondence: Anke Schilhabel,
| | - Monika Szczepanowski
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Ellen J. van Gastel-Mol
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Janina Schillalies
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jill Ray
- Oncology Biomarker Development, Genentech, Inc., South San Francisco, CA, United States
| | - Doris Kim
- Oncology Biomarker Development, Genentech, Inc., South San Francisco, CA, United States
| | - Michaela Nováková
- Childhood Leukemia Investigation Prague (CLIP)-Department of Pediatric Hematology and Oncology, Second Medical Faculty, Charles University and University Hospital Motol, Prague, Czechia
| | - Isabel Dombrink
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Vincent H. J. van der Velden
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sebastian Boettcher
- Department of Medicine III Hematology, Oncology and Palliative Care, University Hospital, Rostock, Germany
| | - Monika Brüggemann
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Michael Kneba
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Jacques J. M. van Dongen
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, Netherlands
| | - Anton W. Langerak
- Laboratory Medical Immunology, Department of Immunology, Erasmus Medical Center (MC), University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Matthias Ritgen
- Hämatologie Labor Kiel, Medical Department II, Hematology and Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Chatzikonstantinou T, Demosthenous C, Baliakas P. Biology and Treatment of High-Risk CLL: Significance of Complex Karyotype. Front Oncol 2021; 11:788761. [PMID: 34912723 PMCID: PMC8667220 DOI: 10.3389/fonc.2021.788761] [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: 10/03/2021] [Accepted: 11/04/2021] [Indexed: 12/23/2022] Open
Abstract
Several reports highlight the clinical significance of cytogenetic complexity, namely, complex karyotype (CK) identified though the performance of chromosome banding analysis (CBA) in chronic lymphocytic leukemia. Indeed, apart from a number of studies underscoring the prognostic and predictive value of CK in the chemo(immune)therapy era, mounting evidence suggests that CK could serve as an independent prognosticator and predictor even in patients treated with novel agents. In the present review, we provide an overview of the current knowledge regarding the clinical impact of CK in CLL, touching upon open issues related to the incorporation of CK in the clinical setting.
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Affiliation(s)
- Thomas Chatzikonstantinou
- Hematology Department-Bone Marrow Transplantation (BMT) Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Christos Demosthenous
- Hematology Department-Bone Marrow Transplantation (BMT) Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Panagiotis Baliakas
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden.,Department of Clinical Genetics, Uppsala University Hospital, Uppsala, Sweden
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6
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Yang S, Kay NE, Shi M, Ossenkoppele G, Walter RB, Gale RP. Measurable residual disease testing in chronic lymphocytic leukaemia: hype, hope neither or both? Leukemia 2021; 35:3364-3370. [PMID: 34580401 DOI: 10.1038/s41375-021-01419-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Shenmiao Yang
- Peking University Peoples Hospital, Peking University Institute of Hematology, Beijing, China
| | - Neil E Kay
- Mayo Clinic, Department of Medicine, Division of Hematology, Rochester, MN, USA
| | - Min Shi
- Mayo Clinic, Department of Laboratory Medicine and Pathology, Rochester, MN, USA
| | - Gert Ossenkoppele
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Roland B Walter
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK.
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7
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Wierda WG, Rawstron A, Cymbalista F, Badoux X, Rossi D, Brown JR, Egle A, Abello V, Cervera Ceballos E, Herishanu Y, Mulligan SP, Niemann CU, Diong CP, Soysal T, Suzuki R, Tran HTT, Wu SJ, Owen C, Stilgenbauer S, Ghia P, Hillmen P. Measurable residual disease in chronic lymphocytic leukemia: expert review and consensus recommendations. Leukemia 2021; 35:3059-3072. [PMID: 34168283 PMCID: PMC8550962 DOI: 10.1038/s41375-021-01241-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022]
Abstract
Assessment of measurable residual disease (often referred to as "minimal residual disease") has emerged as a highly sensitive indicator of disease burden during and at the end of treatment and has been correlated with time-to-event outcomes in chronic lymphocytic leukemia. Undetectable-measurable residual disease status at the end of treatment demonstrated independent prognostic significance in chronic lymphocytic leukemia, correlating with favorable progression-free and overall survival with chemoimmunotherapy. Given its utility in evaluating depth of response, determining measurable residual disease status is now a focus of outcomes in chronic lymphocytic leukemia clinical trials. Increased adoption of measurable residual disease assessment calls for standards for nomenclature and outcomes data reporting. In addition, many basic questions have not been systematically addressed. Here, we present the work of an international, multidisciplinary, 174-member panel convened to identify critical questions on key issues pertaining to measurable residual disease in chronic lymphocytic leukemia, review evaluable data, develop unified answers in conjunction with local expert input, and provide recommendations for future studies. Recommendations are presented regarding methodology for measurable residual disease determination, assay requirements and in which tissue to assess measurable residual disease, timing and frequency of assessment, use of measurable residual disease in clinical practice versus clinical trials, and the future usefulness of measurable residual disease assessment. Nomenclature is also proposed. Adoption of these recommendations will work toward standardizing data acquisition and interpretation in future studies with new treatments with the ultimate objective of improving outcomes and curing chronic lymphocytic leukemia.
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Affiliation(s)
| | | | - Florence Cymbalista
- Hôpital Avicenne, AP-HP, UMR Université Paris13/INSERM U978, Bobigny, France
| | | | - Davide Rossi
- Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Jennifer R Brown
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Alexander Egle
- Department of Internal Medicine III with Haematology, Medical Oncology, Hemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University, Salzburg, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Salzburg, Austria
| | | | | | - Yair Herishanu
- Tel-Aviv Sourasky Medical Center and Sackler Medical School, Tel Aviv, Israel
| | | | | | | | - Teoman Soysal
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | - Shang-Ju Wu
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - Stephan Stilgenbauer
- Internal Medicine III, Ulm University, Ulm and Internal Medicine 1, Saarland University, Homburg, Germany
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
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8
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Al-Sawaf O, Zhang C, Lu T, Liao MZ, Panchal A, Robrecht S, Ching T, Tandon M, Fink AM, Tausch E, Schneider C, Ritgen M, Böttcher S, Kreuzer KA, Chyla B, Miles D, Wendtner CM, Eichhorst B, Stilgenbauer S, Jiang Y, Hallek M, Fischer K. Minimal Residual Disease Dynamics after Venetoclax-Obinutuzumab Treatment: Extended Off-Treatment Follow-up From the Randomized CLL14 Study. J Clin Oncol 2021; 39:4049-4060. [PMID: 34709929 DOI: 10.1200/jco.21.01181] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE The CLL14 study has established one-year fixed-duration treatment of venetoclax and obinutuzumab (Ven-Obi) for patients with previously untreated chronic lymphocytic leukemia. With all patients off treatment for at least three years, we report a detailed analysis of minimal residual disease (MRD) kinetics and long-term outcome of patients treated in the CLL14 study. PATIENTS AND METHODS Patients were randomly assigned to receive six cycles of obinutuzumab with 12 cycles of venetoclax or 12 cycles of chlorambucil (Clb-Obi). Progression-free survival (PFS) was the primary end point. Key secondary end points included rates of undetectable MRD and overall survival. To analyze MRD kinetics, a population-based growth model with nonlinear mixed effects approach was developed. RESULTS Of 432 patients, 216 were assigned to Ven-Obi and 216 to Clb-Obi. Three months after treatment completion, 40% of patients in the Ven-Obi arm (7% in the Clb-Obi arm) had undetectable MRD levels < 10-6 by next-generation sequencing in peripheral blood. Median MRD doubling time was longer after Ven-Obi than Clb-Obi therapy (median 80 v 69 days). At a median follow-up of 52.4 months, a sustained significant PFS improvement was observed in the Ven-Obi arm compared with Clb-Obi (median not reached v 36.4 months; hazard ratio 0.33; 95% CI, 0.25 to 0.45; P < .0001). The estimated 4-year PFS rate was 74.0% in the Ven-Obi and 35.4% in the Clb-Obi arm. No difference in overall survival was observed (hazard ratio 0.85; 95% CI, 0.54 to 1.35; P = .49). No new safety signals occurred. CONCLUSION Appearance of MRD after Ven-Obi is significantly slower than that after Clb-Obi with more effective MRD reduction. These findings translate into a superior long-term efficacy with the majority of Ven-Obi-treated patients remaining in remission.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany.,The Francis Crick Institute, London, United Kingdom.,UCL Cancer Institute, University College London, London, United Kingdom
| | - Can Zhang
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | - Tong Lu
- Genentech, San Francisco, CA
| | | | - Anesh Panchal
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | - Sandra Robrecht
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | | | | | - Anna-Maria Fink
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | - Eugen Tausch
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | | | - Matthias Ritgen
- Department II of Internal Medicine, University of Schleswig- Holstein, Kiel, Germany
| | - Sebastian Böttcher
- Clinic III, Special Hematology Laboratory, Rostock University Medical School, Rostock, Germany
| | - Karl-Anton Kreuzer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | | | | | - Clemens-Martin Wendtner
- Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, Munich Clinic Schwabing, Munich, Germany
| | - Barbara Eichhorst
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Ulm University, Ulm, Germany.,Department of Internal Medicine I, Saarland University Medical Center, Homburg, Germany
| | | | - Michael Hallek
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
| | - Kirsten Fischer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Germany
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9
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Al-Sawaf O, Seymour JF, Kater AP, Fischer K. Should Undetectable Minimal Residual Disease Be the Goal of Chronic Lymphocytic Leukemia Therapy? Hematol Oncol Clin North Am 2021; 35:775-791. [PMID: 34102145 DOI: 10.1016/j.hoc.2021.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With the advent of highly effective novel therapies for chronic lymphocytic leukemia, conventional response assessment is not able to sensitively capture depth of response. To achieve a more precise assessment of response, minimal residual disease has been introduced to more accurately classify and quantify treatment outcomes. It is now considered a strong predictor of outcome in chronic lymphocytic leukemia, although its interpretation depends on the therapeutic context. This review discusses available methods of minimal residual disease measurement. It summarizes minimal residual disease data from pivotal clinical trials and discusses potential implications for future studies and minimal residual disease-based clinical strategies.
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Affiliation(s)
- Othman Al-Sawaf
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
| | - John F Seymour
- Department of Hematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Research Center Amsterdam (LYMMCARE), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Kirsten Fischer
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
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10
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Uchiyama T, Yokoyama A, Aoki S. Measurable residual disease in the treatment of chronic lymphocytic leukemia. J Clin Exp Hematop 2020; 60:138-145. [PMID: 33148932 PMCID: PMC7810249 DOI: 10.3960/jslrt.20014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Treatment outcomes of chronic lymphocytic leukemia (CLL) have improved since
chemoimmunotherapy and novel drugs became available for CLL treatment; therefore, more
sensitive methods to evaluate residual CLL cells in patients are required. Measurable
residual disease (MRD) has been assessed in several clinical trials on CLL using flow
cytometry, real-time quantitative PCR (RQ-PCR) with allele-specific oligonucleotide (ASO)
primers, and high-throughput sequencing. MRD assessment is useful to predict the treatment
outcomes in the context of chemotherapy and treatment with novel drugs such as venetoclax.
In this review, we discuss major techniques for MRD assessment, data from relevant
clinical trials, and the future of MRD assessment in CLL treatment.
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Affiliation(s)
- Takayoshi Uchiyama
- Niigata University of Pharmacy and Applied Life Sciences, Faculty of Pharmaceutical Sciences, Department of Pathophysiology, Niigata, Japan
| | - Aki Yokoyama
- Niigata University of Pharmacy and Applied Life Sciences, Faculty of Pharmaceutical Sciences, Department of Pathophysiology, Niigata, Japan
| | - Sadao Aoki
- Niigata University of Pharmacy and Applied Life Sciences, Faculty of Pharmaceutical Sciences, Department of Pathophysiology, Niigata, Japan
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Phase 1/2 study of venetoclax, a BCL-2 inhibitor, in Japanese patients with relapsed or refractory chronic lymphocytic leukemia and small lymphocytic lymphoma. Int J Hematol 2020; 113:370-380. [PMID: 33094474 DOI: 10.1007/s12185-020-03024-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
Patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) have limited treatment options. Venetoclax is a potent BCL-2 inhibitor that induces apoptosis in CLL cells. This open-label, phase 1/2 study (NCT02265731) evaluated the safety, pharmacokinetics, and efficacy of venetoclax in Japanese patients with R/R CLL/SLL. Patients enrolled in phase 1 received 400 mg/day venetoclax monotherapy. Patients enrolled in phase 2 received 400 mg/day venetoclax, plus rituximab. Venetoclax was administered with a weekly stepwise ramp-up in doses. In phase 2, efficacy was evaluated by objective response rate (ORR). Twelve patients were enrolled, six in each arm. The most common grade ≥ 3 adverse events were neutropenia (83%), lymphopenia (67%), leukopenia (33%), and thrombocytopenia (17%). Patients receiving venetoclax monotherapy achieved an ORR of 100%, including a complete remission (CR) rate of 17%. Patients receiving combination therapy had an ORR of 67% and a CR rate of 50%. The venetoclax pharmacokinetics profile in Japanese patients was similar to that of Western patients. Venetoclax 400 mg/day monotherapy or in combination with rituximab was well-tolerated and induced promising responses in Japanese patients with R/R CLL/SLL. Although patient numbers were small, the safety profile was largely consistent with other Western studies. Clinical trial registration: clinicaltrials.gov; NCT02265731.
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12
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Bosch F, Cantin G, Cortelezzi A, Knauf W, Tiab M, Turgut M, Zaritskey A, Merot JL, Tausch E, Trunzer K, Robson S, Gresko E, Böttcher S, Foà R, Stilgenbauer S, Leblond V. Obinutuzumab plus fludarabine and cyclophosphamide in previously untreated, fit patients with chronic lymphocytic leukemia: a subgroup analysis of the GREEN study. Leukemia 2020; 34:441-450. [PMID: 31455851 PMCID: PMC7214269 DOI: 10.1038/s41375-019-0554-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 12/21/2022]
Abstract
GREEN (NCT01905943) is a nonrandomized, open-label, single-arm, phase 3b study investigating the safety and efficacy of obinutuzumab alone or in combination with chemotherapy in chronic lymphocytic leukemia (CLL). We report the preplanned subgroup analysis of 140 previously untreated, fit CLL patients who received obinutuzumab plus fludarabine and cyclophosphamide (G-FC). The primary endpoint was safety and tolerability. Efficacy was the secondary endpoint. Obinutuzumab 1000 mg was administered intravenously on Day (D)1 (dose split D1‒2), D8 and D15 of Cycle (C)1, and D1 of C2-6 (28-day cycles). Standard intravenous/oral doses of fludarabine and cyclophosphamide were administered on D1-3 of C1-6. Overall, 87.1% of patients experienced grade ≥ 3 adverse events (AEs), including neutropenia (67.1%) and thrombocytopenia (17.1%). Serious AEs were experienced by 42.1% of patients. Rates of grade ≥ 3 infusion-related reactions and infections were 19.3% and 15.7%, respectively. Overall response rate was observed in 90.0%, with 46.4% of patients achieving complete response (CR; including CR with incomplete marrow recovery). Minimal residual disease negativity rates were 64.3% in peripheral blood and 35.7% in bone marrow (intent-to-treat analysis). After a median observation time of 25.6 months, 2 year progression-free survival was 91%. Frontline G-FC represents a promising treatment option for fit patients with CLL.
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Affiliation(s)
| | - Guy Cantin
- Hopital De L'Enfant-Jesus, Quebec City, QC, Canada
| | | | - Wolfgang Knauf
- Onkologische Gemeinschaftspraxis, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
| | - Mourad Tiab
- University Hospital, La Roche Sur Yon, France
| | | | | | | | - Eugen Tausch
- Department of Internal Medicine III, Ulm University, Ulm and Innere Medizin I, Universitätsklinikum des Saarlandes, Homburg, Germany
| | | | | | | | - Sebastian Böttcher
- Second Department of Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany and Clinic III, Hematology, Oncology and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Robin Foà
- Hematology, Sapienza University, Rome, Italy
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Ulm University, Ulm and Innere Medizin I, Universitätsklinikum des Saarlandes, Homburg, Germany
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13
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Brander D, Islam P, Barrientos JC. Tailored Treatment Strategies for Chronic Lymphocytic Leukemia in a Rapidly Changing Era. Am Soc Clin Oncol Educ Book 2019; 39:487-498. [PMID: 31099686 DOI: 10.1200/edbk_238735] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The treatment landscape for chronic lymphocytic leukemia (CLL) is rapidly evolving, with multiple agents recently approved. They include a glycoengineered monoclonal antibody (obinutuzumab), B-cell receptor signaling inhibitors (ibrutinib, idelalisib, and duvelisib), and the BCL-2 inhibitor (venetoclax). These compounds are dramatically changing the natural course of the disease. Nonetheless, despite improved survival rates, particularly in higher-risk disease (older adults, patients with unmutated IGHV, del(11q), and del(17p)/TP53 mutated), there is still room for progress. Given the panoply of highly effective therapies commercially available, it is important to define a tailored treatment strategy for this heterogeneous condition that considers balance of treatment efficacy versus toxicity or tolerance. This article summarizes the most promising clinical advances by reviewing the data from recent clinical trials and discussing meaningful clinical endpoints, including the role of minimal residual disease assessment. The recent development of therapies targeting dysregulated pathways is revolutionary and may ultimately lead us to not only achieve prolonged remission durations but also envision the possibility of a functional cure for a larger population of patients.
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Affiliation(s)
- Danielle Brander
- 1 Duke University Health System, Duke Cancer Institute, Durham, NC
| | - Prioty Islam
- 1 Duke University Health System, Duke Cancer Institute, Durham, NC
| | - Jacqueline C Barrientos
- 2 Northwell Health Cancer Institute, Zucker School of Medicine at Hofstra/Northwell, Feinstein Institute for Medical Research, CLL Research and Treatment Program, New Hyde Park, NY
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14
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Prognostic value of MRD in CLL patients with comorbidities receiving chlorambucil plus obinutuzumab or rituximab. Blood 2018; 133:494-497. [PMID: 30455380 DOI: 10.1182/blood-2018-03-839688] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 10/30/2018] [Indexed: 11/20/2022] Open
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15
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Thompson PA, Peterson CB, Strati P, Jorgensen J, Keating MJ, O'Brien SM, Ferrajoli A, Burger JA, Estrov Z, Jain N, Kadia TM, Borthakur G, DiNardo CD, Daver N, Jabbour E, Wierda WG. Serial minimal residual disease (MRD) monitoring during first-line FCR treatment for CLL may direct individualized therapeutic strategies. Leukemia 2018; 32:2388-2398. [PMID: 29769624 PMCID: PMC6192870 DOI: 10.1038/s41375-018-0132-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 02/12/2018] [Accepted: 03/16/2018] [Indexed: 12/21/2022]
Abstract
Achieving undetectable MRD (U-MRD) status after chemoimmunotherapy predicts longer progression-free and overall survival. The predictive factors and timing of relapse in patients with U-MRD and value of interim MRD analysis are ill-defined. This was a prospective study of 289 patients with CLL treated first-line with FCR. MRD analysis was performed after course 3 (C3) and at end-of-therapy (EOT) in bone marrow using 4-color flow cytometry (sensitivity 10−4). Eighteen percent of patients had U-MRD after C3 and 48% at EOT. U-MRD status at EOT was associated with longer PFS (median NR vs 38mo, p<0.001). MRD level (≤1% vs. >1%) after C3 predicted greater likelihood of U-MRD status at EOT (64% vs. 9%, p<0.001). PFS was significantly longer for patients with MRD ≤1% vs. >1% after C3 (median 73mo vs 41mo, p<0.001), but similar for <0.01% vs. 0.01–1%. Interim MRD status may therefore be used for risk stratification and to individualize therapy. Eighty-five patients with U-MRD status at EOT had yearly blood MRD monitoring; MRD re-emerged in 38/85, a median of 48mo after EOT and preceded clinical progression by a median of 24 months, which may allow development of early intervention strategies.
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christine B Peterson
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Strati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeff Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan M O'Brien
- The Chao Comprehensive Cancer Center, University of California, Irvine, CA, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Hallek M, Shanafelt TD, Eichhorst B. Chronic lymphocytic leukaemia. Lancet 2018; 391:1524-1537. [PMID: 29477250 DOI: 10.1016/s0140-6736(18)30422-7] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/30/2017] [Accepted: 11/13/2017] [Indexed: 12/15/2022]
Abstract
Important advances in understanding the pathogenesis of chronic lymphocytic leukaemia in the past two decades have led to the development of new prognostic tools and novel targeted therapies that have improved clinical outcome. Chronic lymphocytic leukaemia is the most common type of leukaemia in developed countries, and the median age at diagnosis is 72 years. The criteria for initiating treatment rely on the Rai and Binet staging systems and on the presence of disease-related symptoms. For many patients with chronic lymphocytic leukaemia, treatment with chemotherapy and anti-CD20 monoclonal antibodies is the standard of care. The impressive efficacy of kinase inhibitors ibrutinib and idelalisib and the BCL-2 antagonist venetoclax have changed the standard of care in specific subsets of patients. In this Seminar, we review the recent progress in the management of chronic lymphocytic leukaemia and highlight new questions surrounding the optimal disease management.
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MESH Headings
- Adenine/analogs & derivatives
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Diagnosis, Differential
- Genetic Predisposition to Disease
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Mutation
- Piperidines
- Prognosis
- Purines/therapeutic use
- Pyrazoles/therapeutic use
- Pyrimidines/therapeutic use
- Quinazolinones/therapeutic use
- Recurrence
- Risk Factors
- Sulfonamides/therapeutic use
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Michael Hallek
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany.
| | | | - Barbara Eichhorst
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany
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Minimal residual disease analysis in chronic lymphocytic leukemia: a way for achieving more personalized treatments. Leukemia 2018; 32:1307-1316. [DOI: 10.1038/s41375-018-0109-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 11/08/2017] [Accepted: 11/28/2017] [Indexed: 12/28/2022]
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18
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iwCLL guidelines for diagnosis, indications for treatment, response assessment, and supportive management of CLL. Blood 2018. [PMID: 29540348 DOI: 10.1182/blood-2017-09-806398] [Citation(s) in RCA: 948] [Impact Index Per Article: 158.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The previous edition of the consensus guidelines of the International Workshop on Chronic Lymphocytic Leukemia (iwCLL), published in 2008, has found broad acceptance by physicians and investigators caring for patients with CLL. Recent advances including the discovery of the genomic landscape of the disease, the development of genetic tests with prognostic relevance, and the detection of minimal residual disease (MRD), coupled with the increased availability of novel targeted agents with impressive efficacy, prompted an international panel to provide updated evidence- and expert opinion-based recommendations. These recommendations include a revised version of the iwCLL response criteria, an update on the use of MRD status for clinical evaluation, and recommendations regarding the assessment and prophylaxis of viral diseases during management of CLL.
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Kovacs G, Robrecht S, Fink AM, Bahlo J, Cramer P, von Tresckow J, Maurer C, Langerbeins P, Fingerle-Rowson G, Ritgen M, Kneba M, Döhner H, Stilgenbauer S, Klapper W, Wendtner CM, Fischer K, Hallek M, Eichhorst B, Böttcher S. Minimal Residual Disease Assessment Improves Prediction of Outcome in Patients With Chronic Lymphocytic Leukemia (CLL) Who Achieve Partial Response: Comprehensive Analysis of Two Phase III Studies of the German CLL Study Group. J Clin Oncol 2017; 34:3758-3765. [PMID: 27573660 DOI: 10.1200/jco.2016.67.1305] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose To determine the value of minimal residual disease (MRD) assessments, together with the evaluation of clinical response in chronic lymphocytic leukemia according to the 2008 International Workshop on Chronic Lymphocytic Leukemia criteria. Patients and Methods Progression-free survival (PFS) and overall survival of 554 patients from two randomized trials of the German CLL Study Group (CLL8: fludarabine and cyclophosphamide [FC] v FC plus rituximab; CLL10: FC plus rituximab v bendamustine plus rituximab) were analyzed according to MRD assessed in peripheral blood at a threshold of 10-4 and clinical response. The prognostic value of different parameters defining a partial response (PR) was further investigated. Results Patients with MRD-negative complete remission (CR), MRD-negative PR, MRD-positive CR, and MRD-positive PR experienced a median PFS from a landmark at end of treatment of 61 months, 54 months, 35 months, and 21 months, respectively. PFS did not differ significantly between MRD-negative CR and MRD-negative PR; however, PFS was longer for MRD-negative PR than for MRD-positive CR ( P = .048) and for MRD-positive CR compared with MRD-positive PR ( P = .002). Compared with MRD-negative CR, only patients with MRD-positive PR had a significantly shorter overall survival (not reached v 72 months; P = .001), whereas there was no detectable difference for patients with MRD-negative PR or MRD-positive CR ( P = 0.612 and P = 0.853, respectively). Patients with MRD-negative PR who presented with residual splenomegaly had only a similar PFS (63 months) compared with patients with MRD-negative CR (61 months; P = .354), whereas patients with MRD-negative PR with lymphadenopathy showed a shorter PFS (31 months; P < .001). Conclusion MRD quantification allows for improved PFS prediction in both patients who achive PR and CR, which thus supports its application in all responders. In contrast to residual lymphadenopathy, persisting splenomegaly does not impact outcome in patients with MRD-negative PR.
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Affiliation(s)
- Gabor Kovacs
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Sandra Robrecht
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Anna Maria Fink
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Jasmin Bahlo
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Paula Cramer
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Julia von Tresckow
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Christian Maurer
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Petra Langerbeins
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Günter Fingerle-Rowson
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Matthias Ritgen
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Michael Kneba
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Hartmut Döhner
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Stephan Stilgenbauer
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Wolfram Klapper
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Clemens-Martin Wendtner
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Kirsten Fischer
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Michael Hallek
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Barbara Eichhorst
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
| | - Sebastian Böttcher
- Gabor Kovacs, Sandra Robrecht, Anna Maria Fink, Jasmin Bahlo, Paula Cramer, Julia von Tresckow, Christian Maurer, Petra Langerbeins, Kirsten Fischer, Michael Hallek, and Barbara Eichhorst, University of Cologne and Center of Integrated Oncology Cologne/Bonn, Cologne; Matthias Ritgen, Michael Kneba, and Sebastian Böttcher, University of Schleswig-Holstein, Lubeck; Hartmut Döhner and Stephan Stilgenbauer, University of Ulm, Ulm; Wolfram Klapper, University of Kiel, Kiel; Clemens-Martin Wendtner, Klinikum Schwabing, Munich, Germany; and Günter Fingerle-Rowson, F. Hoffmann La-Roche, Basel, Switzerland
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21
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Hallek M. Chronic lymphocytic leukemia: 2017 update on diagnosis, risk stratification, and treatment. Am J Hematol 2017; 92:946-965. [PMID: 28782884 DOI: 10.1002/ajh.24826] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen and B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) and/or mutations of the TP53 gene predict resistance to available chemotherapies. A comprehensive prognostic score (CLL-IPI) using genetic, biological, and clinical variables has recently been developed allowing to classify CLL into very distinct risk groups. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physically fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab remains the current standard therapy. For unfit patients, currently available evidence supports two options for a first-line therapy: chlorambucil combined with an anti-CD20 antibody (obinutuzumab or rituximab or ofatumumab) or a continuous therapy with ibrutinib. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds 3 years. If the disease relapses earlier, therapy should be changed using alternative agents such as bendamustine (plus rituximab), alemtuzumab, lenalidomide, ofatumumab, ibrutinib, idelalisib, or venetoclax. Patients with a del(17p) or TP53 mutation can be treated with ibrutinib, venetoclax, or a combination of idelalisib and rituximab. An allogeneic SCT may be considered in relapsing patients with TP53 mutations or del(17p) or patients that are refractory to chemoimmunotherapy and the novel inhibitors. FUTURE CHALLENGES The new agents (ibrutinib, idelalisib, venetoclax, and obinutuzumab) hold the potential to significantly improve the outcome of CLL patients. However, their optimal use (in terms of combination, sequence, and duration) remains unknown. Therefore, CLL patients should be treated in clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Kerpener Strasse 62 Köln 50937 Germany
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22
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High-throughput sequencing for noninvasive disease detection in hematologic malignancies. Blood 2017; 130:440-452. [PMID: 28600337 DOI: 10.1182/blood-2017-03-735639] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/25/2017] [Indexed: 12/20/2022] Open
Abstract
Noninvasive monitoring of minimal residual disease (MRD) has led to significant advances in personalized management of patients with hematologic malignancies. Improved therapeutic options and prolonged survival have further increased the need for sensitive tumor assessment that can inform treatment decisions and patient outcomes. At diagnosis or relapse of most hematologic neoplasms, malignant cells are often easily accessible in the blood as circulating tumor cells (CTCs), making them ideal targets to noninvasively profile the molecular features of each patient. In other cancer types, CTCs are generally rare and noninvasive molecular detection relies on circulating tumor DNA (ctDNA) shed from tumor deposits into circulation. The ability to precisely detect and quantify CTCs and ctDNA could minimize invasive procedures and improve prediction of clinical outcomes. Technical advances in MRD detection methods in recent years have led to reduced costs and increased sensitivity, specificity, and applicability. Among currently available tests, high-throughput sequencing (HTS)-based approaches are increasingly attractive for noninvasive molecular testing. HTS-based methods can simultaneously identify multiple genetic markers with high sensitivity and specificity without individual optimization. In this review, we present an overview of techniques used for noninvasive molecular disease detection in selected myeloid and lymphoid neoplasms, with a focus on the current and future role of HTS-based assays.
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23
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Rodrigues CA, Gonçalves MV, Ikoma MRV, Lorand-Metze I, Pereira AD, Farias DLCD, Chauffaille MDLLF, Schaffel R, Ribeiro EFO, Rocha TSD, Buccheri V, Vasconcelos Y, Figueiredo VLDP, Chiattone CS, Yamamoto M. Diagnosis and treatment of chronic lymphocytic leukemia: recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia. Rev Bras Hematol Hemoter 2016; 38:346-357. [PMID: 27863764 PMCID: PMC5119662 DOI: 10.1016/j.bjhh.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic lymphocytic leukemia is characterized by clonal proliferation and progressive accumulation of B-cell lymphocytes that typically express CD19+, CD5+ and CD23+. The lymphocytes usually infiltrate the bone marrow, peripheral blood, lymph nodes, and spleen. The diagnosis is established by immunophenotyping circulating B-lymphocytes, and prognosis is defined by two staging systems (Rai and Binet) established by physical examination and blood counts, as well as by several biological and genetic markers. In this update, we present the recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia for the diagnosis and treatment of chronic lymphocytic leukemia. The following recommendations are based on an extensive literature review with the aim of contributing to more uniform patient care in Brazil and possibly in other countries with a similar social–economic profile.
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Affiliation(s)
- Celso Arrais Rodrigues
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Hospital Sírio Libanês, São Paulo, SP, Brazil.
| | - Matheus Vescovi Gonçalves
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Fleury Medicina e Saúde, São Paulo, SP, Brazil
| | | | | | | | | | | | - Rony Schaffel
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | - Talita Silveira da Rocha
- A.C Camargo Cancer Center, São Paulo, SP, Brazil; Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Valeria Buccheri
- Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP, Brazil
| | - Yuri Vasconcelos
- Instituto Goiano de Oncologia e Hematologia (INGOH), Goiânia, GO, Brazil
| | | | - Carlos Sérgio Chiattone
- Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Hospital Samaritano, São Paulo, SP, Brazil
| | - Mihoko Yamamoto
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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24
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Eliminating minimal residual disease as a therapeutic end point: working toward cure for patients with CLL. Blood 2015; 127:279-86. [PMID: 26576865 DOI: 10.1182/blood-2015-08-634816] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022] Open
Abstract
Deep remission and prolonged disease-free survival can be achieved with first-line chemoimmunotherapy (CIT), such as combined fludarabine, cyclophosphamide, and rituximab, in the majority of patients with chronic lymphocytic leukemia (CLL). More modest results are reported with less intense regimens like obinutuzumab plus chlorambucil. Clinical assessment has limited sensitivity in detecting residual disease responsible for subsequent relapse, even including morphologic bone marrow (BM) evaluation. Multicolor flow cytometry and polymerase chain reaction (PCR)-based methods can detect minimal residual disease (MRD) to a sensitivity of ≥1:10,000 (10(-4)). Achieving BM MRD-negative complete remission (CR) is associated with superior progression-free survival (PFS) and overall survival; MRD status is the single best posttreatment predictor of long-term outcomes after CIT. Newer oral B-cell receptor signaling pathway inhibitors are highly effective at controlling disease, but best monotherapy responses are typically partial remission, and patients must remain on treatment to maintain disease control. Therapeutic progress is still needed for CLL. We propose that targeting MRD provides opportunity to realize this progress. Achieving BM MRD-negative CR is a prerequisite for long-term unmaintained disease-free survival and potential for cure. We review available methodologies for detecting MRD and correlations with posttreatment outcomes. We discuss the potential utility of MRD to direct individualized therapy. Finally, we discuss the importance of MRD-negative status as a surrogate marker for longer PFS in clinical studies to allow more rapid determination of clinical benefit.
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25
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A drive through cellular therapy for CLL in 2015: allogeneic cell transplantation and CARs. Blood 2015; 126:478-85. [DOI: 10.1182/blood-2015-03-585091] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/09/2015] [Indexed: 12/13/2022] Open
Abstract
Abstract
Over the past decade the development of safer reduced-intensity conditioning regimens, expanded donor pools, advances in supportive care, and prevention/management of graft-versus-host disease have expanded stem cell transplantation (SCT) availability for chronic lymphocytic leukemia (CLL) patients. However, there are now increasingly active treatment options available for CLL patients with favorable toxicity profiles and convenient administration schedules. This raises the critical issue of whether or not attainment of cure remains a necessary goal. It is now less clear that treatment with curative intention and with significant toxicity is required for long-term survival in CLL. In addition, the demonstrated safety and activity of genetically modified chimeric antigen receptor (CAR) T cells present the opportunity of harnessing the power of the immune system to kill CLL cells without the need for SCT. We attempt to define the role of SCT in the era of targeted therapies and discuss questions that remain to be answered. Furthermore, we highlight the potential for exciting new cellular therapy using genetically modified anti-CD19 CAR T cells and discuss its potential to alter treatment paradigms for CLL.
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26
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Shadman M, Gopal AK, Kammerer B, Becker PS, Maloney DG, Pender B, Shustov AR, Press OW, Pagel JM. Radioimmunotherapy consolidation using 131I-tositumomab for patients with chronic lymphocytic leukemia or small lymphocytic lymphoma in first remission. Leuk Lymphoma 2015; 57:572-6. [PMID: 26133724 DOI: 10.3109/10428194.2015.1067701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite initial responses to chemoimmunotherapy, relapse and minimal residual disease (MRD) remain major issues in treatment of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) patients. We administered (131)I-tositumomab to patients in complete response (CR) or partial response (PR) after induction chemotherapy. Toxicities and rate of PR to CR conversion and MRD elimination were assessed three months later. The study stopped prematurely after enrolling 16 patients. Four (25%) were in CR, 12 (75%) in PR, and 12 (75%) had MRD. Three months after treatment with (131)I-tositumomab, CR was achieved (n = 8; 50%) or sustained (n = 4; 25%) in 12 patients and MRD was eliminated in four of 12 patients (33%). Hematologic toxicities were anemia in one patient (6%), neutropenia in 13 (81%), and thrombocytopenia in eight (50%). Two patients (12%) developed MDS 17 and 20 months after consolidation. Consolidation with (131)I-tositumomab for CLL/SLL patients in first remission is feasible and may provide the benefit of converting PR to CR and/or eliminating MRD.
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Affiliation(s)
- Mazyar Shadman
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Ajay K Gopal
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Britt Kammerer
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Pamela S Becker
- b Department of Medicine , University of Washington , Seattle , WA , USA
| | - David G Maloney
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Barbara Pender
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Andrei R Shustov
- b Department of Medicine , University of Washington , Seattle , WA , USA
| | - Oliver W Press
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
| | - John M Pagel
- a Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,b Department of Medicine , University of Washington , Seattle , WA , USA
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27
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Hallek M. Chronic lymphocytic leukemia: 2015 Update on diagnosis, risk stratification, and treatment. Am J Hematol 2015; 90:446-60. [PMID: 25908509 DOI: 10.1002/ajh.23979] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) predict resistance to available chemotherapies. Comprehensive prognostic scores are currently being developed. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physical fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab remains the current standard therapy. For unfit patients, treatment with an anti-CD20 antibody (obinutuzumab or rituximab or ofatumumab) plus a milder chemotherapy (Chlorambucil) may be applied. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds two to three years. If the disease relapses earlier, therapy should be changed using alternative agents such as bendamustine (plus rituximab), alemtuzumab, lenalidomide, ofatumumab, ibrutinib, or idelalisib. Patients with a del(17p) or TP53 mutation can be treated with ibrutinib or a combination of idelalisib and rituximab. An allogeneic SCT may be considered in relapsing patients with TP53 mutations or del(17p) or patients that are refractory to repeated chemoimmunotherapies. Future challenges: Several new agents (e.g., ibrutinib, idelalisib, obinutuzumab) hold the potential to improve the outcome of patients with CLL. However, their optimal use (in terms of combination, sequence, and duration) is unknown. Therefore, CLL patients should be treated in clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases”, University of Cologne; Cologne Germany
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28
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Cerquozzi S, Owen C. Clinical role of obinutuzumab in the treatment of naive patients with chronic lymphocytic leukemia. Biologics 2015; 9:13-22. [PMID: 25733804 PMCID: PMC4337412 DOI: 10.2147/btt.s61600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The introduction of targeted therapy against CD20+ with the monoclonal antibody rituximab has dramatically improved the survival of B-cell non-Hodgkin lymphoma including chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma. Unfortunately, CLL remains incurable with chemoimmunotherapy, with many patients having refractory or relapsing disease after rituximab-containing therapy. Obinutuzumab (GA101) is a novel humanized Type II anti-CD20 monoclonal antibody that has been investigated and compared to rituximab. Here, we provide an overview of obinutuzumab, including its mechanisms of action, preclinical data, and Phase I to III clinical studies. Preclinical data illustrate obinutuzumab’s higher potency compared to rituximab through antibody-dependent cellular cytotoxicity and direct cell death. Recently, the CLL11 study presented a significant benefit from obinutuzumab chemoimmunotherapy and supports its use for treatment-naive unfit CLL patients. Herein, we review that obinutuzumab is both a safe and effective alternative to rituximab.
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Affiliation(s)
- Sonia Cerquozzi
- Department of Hematology, University of Calgary, Calgary, AB, Canada
| | - Carolyn Owen
- Department of Hematology, Tom Baker Cancer Centre, Calgary, AB, Canada
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29
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Prognosis and therapy of chronic lymphocytic leukemia and small lymphocytic lymphoma. Cancer Treat Res 2015; 165:147-75. [PMID: 25655609 DOI: 10.1007/978-3-319-13150-4_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by a highly variable clinical course that has guided treatment principles in as much as anti-leukemic therapy is reserved for patients with active disease. This heterogeneity is somewhat dissected by prognostic markers, many of which represent pathogenic mechanisms. Recently, the introduction of highly active targeted agents and maturing data on predictive markers may lead to more individualized therapeutic approaches. In this chapter, we review key prognostic markers, current and emerging therapy, and will attempt to outline a future "where the two may connect".
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30
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Hourigan CS, McCarthy P, de Lima M. Reprint of: Back to the future! The evolving role of maintenance therapy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2014; 20:S8-S17. [PMID: 24485019 DOI: 10.1016/j.bbmt.2014.01.005] [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] [Received: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 11/26/2022]
Abstract
Relapse is a devastating event for patients with hematologic cancers treated with hematopoietic stem cell transplantation. In most situations, relapse treatment options are limited. Maintenance therapy offers the possibility of delaying or avoiding disease recurrence, but its role remains unclear in most conditions that we treat with transplantation. Here, Dr. Hourigan presents an overview of minimal residual disease (MRD) measurement in hematologic malignancies and the applicability of MRD-based post-transplantation interventions. Dr. McCarthy reviews current knowledge of maintenance therapy in the autologous transplantation context, with emphasis on immunologic interventions and immune modulation strategies designed to prevent relapse. Dr. de Lima discusses current lines of investigation in disease recurrence prevention after allogeneic transplantation, focusing on acute myeloid leukemia and myelodysplastic syndrome.
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Affiliation(s)
- Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Philip McCarthy
- Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, New York
| | - Marcos de Lima
- University Hospitals Case Medical Center, Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
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31
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Pallasch CP, Hallek M. Incorporating Targeted Agents Into Future Therapy of Chronic Lymphocytic Leukemia. Semin Hematol 2014; 51:235-48. [DOI: 10.1053/j.seminhematol.2014.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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32
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Ghia P, Hallek M. Management of chronic lymphocytic leukemia. Haematologica 2014; 99:965-72. [PMID: 24881042 PMCID: PMC4040893 DOI: 10.3324/haematol.2013.096107] [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: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 12/22/2022] Open
Abstract
In the last decade, the management of chronic lymphocytic leukemia has undergone profound changes that have been driven by an improved understanding of the biology of the disease and the approval of several new drugs. Moreover, many novel drugs are currently under evaluation for rapid approval or have been approved by regulatory agencies, further broadening the available therapeutic armamentarium for patients with chronic lymphocytic leukemia. The use of novel biological and genetic parameters combined with a careful clinical evaluation allows us to dissect some of the heterogeneity of the disease and to distinguish patients with a very mild onset and course, who often will not need any treatment, from those with an intermediate prognosis and a third group with a very aggressive course (high-risk leukemia). On this background, it becomes increasingly challenging to select the right treatment strategy. In this paper, we describe our own approach to the management of different patients with chronic lymphocytic leukemia.
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Affiliation(s)
- Paolo Ghia
- Clinical Unit of Lymphoid Malignancies and Laboratory of B Cell Neoplasia, Department of Onco-Hematology and Division of Molecular Oncology, Università Vita-Salute San Raffaele, Fondazione Centro San Raffaele, IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Michael Hallek
- Department I Internal Medicine, Center for Integrated Oncology Köln-Bonn, Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Germany
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33
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Abstract
AbstractThe management of chronic lymphocytic leukemia (CLL) is undergoing profound changes. Several new drugs have been approved for CLL treatment (fludarabine, bendamustine, and the monoclonal antibodies alemtuzumab, rituximab, and ofatumumab) and many more drugs are in advanced clinical development to be approved for this disease. In addition, the extreme heterogeneity of the clinical course and our improved ability to foresee the prognosis of this leukemia by the use of clinical, biological, and genetic parameters now allow us to characterize patients with a very mild onset and course, an intermediate prognosis, or a very aggressive course with high-risk leukemia. Therefore, it becomes increasingly challenging to select the right treatment strategy for each condition. This article summarizes the currently available diagnostic and therapeutic tools and gives an integrated recommendation of how to manage CLL in 2013. Moreover, I propose a strategy how we might integrate the novel agents for CLL therapy into sequential treatment approaches in the near future.
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34
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Abstract
AbstractThe management of chronic lymphocytic leukemia (CLL) is undergoing profound changes. Several new drugs have been approved for CLL treatment (fludarabine, bendamustine, and the monoclonal antibodies alemtuzumab, rituximab, and ofatumumab) and many more drugs are in advanced clinical development to be approved for this disease. In addition, the extreme heterogeneity of the clinical course and our improved ability to foresee the prognosis of this leukemia by the use of clinical, biological, and genetic parameters now allow us to characterize patients with a very mild onset and course, an intermediate prognosis, or a very aggressive course with high-risk leukemia. Therefore, it becomes increasingly challenging to select the right treatment strategy for each condition. This article summarizes the currently available diagnostic and therapeutic tools and gives an integrated recommendation of how to manage CLL in 2013. Moreover, I propose a strategy how we might integrate the novel agents for CLL therapy into sequential treatment approaches in the near future.
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35
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Hourigan CS, McCarthy P, de Lima M. Back to the future! The evolving role of maintenance therapy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2013; 20:154-63. [PMID: 24291784 DOI: 10.1016/j.bbmt.2013.11.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 12/28/2022]
Abstract
Relapse is a devastating event for patients with hematologic cancers treated with hematopoietic stem cell transplantation. In most situations, relapse treatment options are limited. Maintenance therapy offers the possibility of delaying or avoiding disease recurrence, but its role remains unclear in most conditions that we treat with transplantation. Here, Dr. Hourigan presents an overview of minimal residual disease (MRD) measurement in hematologic malignancies and the applicability of MRD-based post-transplantation interventions. Dr. McCarthy reviews current knowledge of maintenance therapy in the autologous transplantation context, with emphasis on immunologic interventions and immune modulation strategies designed to prevent relapse. Dr. de Lima discusses current lines of investigation in disease recurrence prevention after allogeneic transplantation, focusing on acute myeloid leukemia and myelodysplastic syndrome.
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Affiliation(s)
- Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | - Philip McCarthy
- Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, New York
| | - Marcos de Lima
- University Hospitals Case Medical Center, Seidman Cancer Center, Case Western Reserve University, Cleveland, Ohio.
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Hallek M. Chronic lymphocytic leukemia: 2013 update on diagnosis, risk stratification and treatment. Am J Hematol 2013; 88:803-16. [PMID: 23720127 DOI: 10.1002/ajh.23491] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) predict resistance to most available therapies. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physical fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide and rituximab represents the current standard therapy. For unfit patients, treatment with an anti-CD20 antibody plus a milder chemotherapy (chlorambucil) is currently established as standard treatment. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds two years. If the disease relapses earlier, alternative therapies such as bendamustine alone or with rituximab, alemtuzumab, lenalidomide, or ofatumumab should be used. Patients with a del(17p) or TP53 should be considered for an allogeneic SCT. FUTURE CHALLENGES Several new agents (e.g., ibrutinib, obinutuzumab) hold the potential to change standard of CLL treatment in the next 6-12 months. Therefore, CLL patients should be included into current clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; University of Cologne, Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases,”; Germany
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Gribben JG, Riches JC. Immunotherapeutic strategies including transplantation: eradication of disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:151-157. [PMID: 24319176 DOI: 10.1182/asheducation-2013.1.151] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Although there have been recent advances with targeted therapies in chronic lymphocytic leukemia (CLL), chemoimmunotherapy remains the treatment of choice; however, this approach is not curative. A key feature of CLL is that it induces a state of immunosuppression, causing increased susceptibility to infections and failure of an antitumor immune response, often worsened by the immunosuppressive effect of treatment. Because of its improved specificity, immunotherapy potentially offers a way out of this dilemma. Allogeneic stem cell transplantation remains the only curative option, but is hampered by the toxicity of GVHD. After many years of promise but little reward, many other immunotherapeutic approaches are now in transition to the clinical setting. Clinical trials including CLL vaccines, CXCR4 antagonists, and adoptive cellular immunotherapies such as chimeric antigen receptor-modified T cells, CD40 ligand gene therapy, and the immunomodulatory drug lenalidomide are ongoing. Results to date suggest that immunotherapeutic approaches for the treatment of CLL might finally be fulfilling their promise.
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Affiliation(s)
- John G Gribben
- 1Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
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