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Baratè C, Sanna A, Benedetti E, Bocchia M, Capochiani E, Danesi R, Moretti S, Occhini U, Santini S, Galimberti S, Gozzetti A. Real-life diagnostic and therapeutic approach to CLL: a 2022 update from an expert panel in Tuscany. Clin Exp Med 2023; 23:4251-4264. [PMID: 37979127 DOI: 10.1007/s10238-023-01244-5] [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: 02/24/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
A panel of chronic lymphocytic leukemia (CLL) experts from Tuscany propose a real-life diagnostic and therapeutic approach CLL that considers the role of genomic and somatic prognostic factors in risk stratification and treatment decisions. Safety and efficacy of new agents has been demonstrated now not only in clinical trials but also in many real-world series. The BTK inhibitors, ibrutinib and acalabrutinib, and BH3 mimetic venetoclax are now indicated as first-line therapy and chemoimmunotherapy can be spared to the majority of CLL patients, thus preventing unnecessary hematological and non-hematological toxicity and second primary tumors. For treatment, FISH for 17 p and P53 mutational status are essential. IGHV mutation can be done at diagnosis or before treatment. Echography is the gold standard radiological investigation in CLL, at both diagnosis and response evaluation. Chemotherapy is virtually abandoned. Age, genetic risk, and patient comorbidities have to be carefully evaluated for treatment decision. With the availability of different drugs, there is a need for a uniform and shared approach in daily therapeutic choice. The proposed approach is based on current evidence and guidelines as well as results from clinical trials and daily clinical experience.
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Affiliation(s)
- Claudia Baratè
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Edoardo Benedetti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), Pisa, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Enrico Capochiani
- Hematology Unit, Department of Internal Medicine, Toscana Nord Ovest, Leghorn, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | | | | | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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Gogia A, Gupta R, Sharma A, kumar L, rani L, Mallick S. Safety and Efficacy of Bendamustine and Rituximab (BR) Regimen in Indian Chronic Lymphocytic Leukaemia Patients. Indian J Hematol Blood Transfus 2023; 39:33-39. [PMID: 36699426 PMCID: PMC9868021 DOI: 10.1007/s12288-022-01544-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/19/2022] [Indexed: 01/28/2023] Open
Abstract
We investigated the safety and efficacy of bendamustine-rituximab (BR) in previously untreated symptomatic and advanced CLL patients, as there is no data available on BR from the Indian subcontinent.This retrospective study included 120 consecutive treatment naïve patients with CLL without del (17p), who were registered at the Department of Medical Oncology, AIIMS between January 2010 and July 2018. Bendamustine was given at a dose of 90 mg/m2 on days 1 and 2, combined with rituximab 375 mg/m2 rituximab on day 1, every 28 days for up to 6 courses. Event-free survival (EFS) was defined as the date of treatment to date of relapse, disease progression, or death due to any cause.The median age was 57 years (range: 30-75 years). As per the clinical Rai stage, 30 (25%) patients were in stage II, 42 (35%) were in stage III and 48 (40%) were in stage IV. ZAP70 was positive (> 20%) in 50%, CD 38 was positive (> 30%) in 33%, and CD49d was positive (> 30%) in 49% of cases. Beta-2 microglobulin (B2M) was elevated (≥ 3.5 mg/L) in 80% of cases. Fifty-five cases (50%, n = 110) were IGHV mutated. The mean number of cycles was 5 (1-6). The overall response rate (ORR) seen with BR was 90% and complete response was 45%. Median progression-free survival was 24 months with a median follow-up period of 29 months. Haemoglobin (< 10 g/dL), elevated B2 M, unmutated IGHV had a statistically significant adverse impact on EFS on univariate analysis but on multivariate analysis, only IGHV mutation status was found to had significance on EFS. The median EFS was 27 months in IGHV mutated versus 18 months in IGHV unmutated-CLL patients (p = 0.001). Grade 3/4 neutropenia, thrombocytopenia, anemia, and infections were observed in 30.6%, 8%, and 12% respectively. The most common non-hematological toxicity was skin rash which was grade 1/2 in 24 (20%) cases and grade 3/4 in 12 (10%) cases. This is the largest study from India to demonstrate the safety and efficacy of BR in symptomatic CLL patients. BR is an effective and safe regimen in the first-line treatment of CLL. Unmutated-CLL patients have inferior EFS than mutated-CLL patients. Skin toxicity was the most common adverse effect seen in our population which was observed in around one-third of cases.
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Affiliation(s)
- Ajay Gogia
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Ritu Gupta
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Lalit kumar
- Department of Medical Oncology, IRCH, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Lata rani
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Saumyaranjan Mallick
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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Bacchiarri F, Gozzetti A, Mondanelli N, Lazzi S, Bocchia M. A case of bone lesion in a patient with relapsed chronic lymphocytic leukemia and review of the literature. Clin Case Rep 2022; 10:e05379. [PMID: 35414919 PMCID: PMC8979145 DOI: 10.1002/ccr3.5379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 07/25/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
Abstract
Skeletal involvement in CLL is very rare. We present a case of ileum bone lesion during in a patient receiving 5th line of therapy. Despite radiotherapy and salvage therapies, subsequent bone lesions led to a fatal outcome. Further studies on the mechanism by which bone disease develops are currently needed.
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Affiliation(s)
| | | | | | - Stefano Lazzi
- Anatomic Pathology Department University of Siena Siena Italy
| | - Monica Bocchia
- Department of Hematology University of Siena Siena Italy
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Bourrier N, Landego I, Bucher O, Squires M, Streu E, Hibbert I, Whiteside T, Gibson SB, Geirnaert M, Johnston JB, Dawe DE, Banerji V. Real world risk of infusion reactions and effectiveness of front-line obinutuzumab plus chlorambucil compared with other frontline treatments for chronic lymphocytic leukemia. BMC Cancer 2022; 22:148. [PMID: 35123433 PMCID: PMC8818183 DOI: 10.1186/s12885-022-09256-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in North America. Previous studies have shown improved progression free survival (PFS) and response rates in unfit patients treated with obinutuzumab compared to other regimens. The aim of this study was to evaluate the obinutuzumab-chlorambucil regimen in the context of historical treatments and first-dose infusion reactions at CancerCare Manitoba (CCMB). Methods A retrospective chart review was conducted for patients treated with obinutuzumab from January 1, 2014 to December 31, 2017 at CCMB. A minimum data set was extracted for patients treated with other front-line therapies. Descriptive statistics were used to evaluate patient demographics, toxicity, duration and dosing of obinutuzumab treatment. Kaplan–Meier curves were used to evaluate time-to-next-treatment (TTNT), overall survival (OS) and PFS for patients treated with obinutuzumab. A multivariable logistic regression model was used to investigate associations between infusion related reactions (IRRs) and age at treatment, pre-treatment lymphocyte count, cumulative illness rating scale (CIRS) and receipt of prior chemotherapy. Results Forty seven percent of patients receiving frontline therapy received chlorambucil and obinutuzumab. Sixty-seven patients were treated with obinutuzumab and consisted of 36 males (53.7%) and 31 females (46.3%) with 29 patients (43.3%) over age 75 years. Rates of grade 3 and 4 obinutuzumab IRRs were lower (6%) compared to the CLL11 clinical trial (20%) due to local practices including slower infusion rates and using chlorambucil before starting obinutuzumab treatment. Many patients had difficulty tolerating the full dosage of chlorambucil. Only 26 patients (38.8%) had their dose of chlorambucil escalated to the full dose of 0.5 mg/kg. In addition, only 18 patients (26.9%) received all doses of obinutuzumab and all 12 doses of chlorambucil. Conclusions In summary, first dose infusion reactions with obinutuzumab can be markedly reduced by using chlorambucil to decrease the lymphocyte count before obinutuzumab and by using a very slow initial obinutuzumab infusion rate. Modifications in chlorambucil dosing and obinutuzumab administration can improve tolerance without significant loss in efficacy. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09256-2.
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Autoimmune Cytopenia in CLL: Prognosis and Management in the Era of Targeted Therapies. ACTA ACUST UNITED AC 2021; 27:286-296. [PMID: 34398555 DOI: 10.1097/ppo.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic lymphocytic leukemia (CLL) is frequently associated with autoimmune hemolytic anemia and immune thrombocytopenia and, less frequently, with pure red cell aplasia and immune neutropenia. The emergence of these complications is related to an intertwined and complex relationship between patient, disease, and treatment characteristics. The prognostic repercussion of autoimmune cytopenia (AIC) in patients with CLL mainly depends on its response to therapy. For patients with AIC and nonactive CLL, treatment is as in primary, uncomplicated AIC, keeping in mind that no response is an indication for CLL therapy. The success of treating active CLL-related AIC widely relies on a flexible strategy that should include initial therapy with corticosteroids and a rapid shift to effective CLL therapy in nonresponding patients. Targeted therapies (e.g., ibrutinib) that have already demonstrated to be effective in CLL-related AIC will likely offer a unique possibility of treating both AIC and CLL as a single target.
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Rashid B, Jalal S, Yassin A, Hassan K, Mohamed Z, Ahmed Z, Mahmood T, Shamoon R, Mustafa S, Karam M, Abdullah D, Mohammad S, Abdulrahman L, Yousif RH, Abdulla B, Mohammed N, Getta H, Polus R, Numan G. Impact of clinical staging and demographic data (age and sex) on response to treatment and survival of chronic lymphocytic leukemia patients in Kurdistan Region of Iraq. IRAQI JOURNAL OF HEMATOLOGY 2021. [DOI: 10.4103/ijh.ijh_11_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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7
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Mattsson A, Sylvan SE, Asklid A, Wiggh J, Winqvist M, Lundin J, Mansouri L, Rosenquist R, Johansson H, Österborg A, Hansson L. Risk-adapted bendamustine + rituximab is a tolerable treatment alternative for elderly patients with chronic lymphocytic leukaemia: a regional real-world report on 141 consecutive Swedish patients. Br J Haematol 2020; 191:426-432. [PMID: 32779190 PMCID: PMC7689859 DOI: 10.1111/bjh.17032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 11/26/2022]
Abstract
Bendamustine + rituximab (BR) is the current first-line standard-of-care for chronic lymphocytic leukaemia (CLL) in fit patients aged 66-70 years, whereas chlorambucil + CD20 antibody is recommended in older patients with co-morbidities. This retrospective real-world study investigated whether risk-adapted BR was safe and effective in elderly patients. All 141 CLL patients in the Stockholm region (diagnosed from 2007 to 2016, identified from regional registries) who had received BR as first (n = 84) or later line (n = 57) were analysed. Median age was 72 years, 49% had Binet stage C, 40% had Cumulative Illness Rating Scale (CIRS) score ≥ 6, 20% Eastern Cooperative Oncology Group (ECOG) score 2. None had del(17p). Only 15% of patients aged ≥80 years received full-dose bendamustine and 65% of them postponed rituximab until cycle 2. Corresponding numbers in patients 73-79 years were 21% and 36% and in <73 years, 63% and 33%. Overall response rate was 83% (first line) and 67% (later line) (P < 0·022) equally distributed between age subsets. ECOG, immunoglobulin heavy chain variable region (IGHV) mutational status and cytogenetics, but not treatment line and age, were significant factors on progression-free survival (PFS) in multivariate analysis. Infections and neutropenia/thrombocytopenia (≥grade 3) were similar across age subgroups. In summary, BR was well tolerated even in patients ≥80 years, with similar efficacy and safety as in less old patients, provided that carefully adapted dosing was applied.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride/administration & dosage
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Prognosis
- Retrospective Studies
- Rituximab/administration & dosage
- Sweden/epidemiology
- Treatment Outcome
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Affiliation(s)
- Agnes Mattsson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of Internal MedicineSödersjukhusetStockholmSweden
| | - Sandra E. Sylvan
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
| | - Anna Asklid
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of OncologyKarolinska University HospitalStockholmSweden
| | - Joel Wiggh
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Maria Winqvist
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Jeanette Lundin
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Larry Mansouri
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Richard Rosenquist
- Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Hemming Johansson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
| | - Anders Österborg
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
| | - Lotta Hansson
- Department of Oncology‐PathologyKarolinska InstitutetStockholmSweden
- Department of HematologyKarolinska University HospitalStockholmSweden
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8
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Mondello P, Zelenetz AD. Reshaping the therapeutic landscape of chronic lymphocytic leukaemia in the era of targeted therapy. Br J Haematol 2020; 191:326-328. [PMID: 32761826 DOI: 10.1111/bjh.17031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Patrizia Mondello
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew D Zelenetz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Autore F, Innocenti I, Corrente F, Del Principe MI, Rosati S, Falcucci P, Fresa A, Conte E, Limongiello MA, Renzi D, De Padua L, Andriani A, Pisani F, Cimino G, Tafuri A, Montanaro M, Mauro FR, Del Poeta G, Laurenti L. Front-Line Therapy for Elderly Chronic Lymphocytic Leukemia Patients: Bendamustine Plus Rituximab or Chlorambucil Plus Rituximab? Real-Life Retrospective Multicenter Study in the Lazio Region. Front Oncol 2020; 10:848. [PMID: 32587827 PMCID: PMC7298101 DOI: 10.3389/fonc.2020.00848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022] Open
Abstract
Previous studies investigated the efficacy and the safety of bendamustine (B) vs. chlorambucil (Chl) associated with rituximab (R) in fludarabine-ineligible patients with treated and untreated chronic lymphocytic leukemia (CLL). We conducted a retrospective multicenter study in the Lazio region to further evaluate and compare the efficacy and the toxicity of Chl-R and B-R regimen in CLL patients over the age of 65. We enrolled 192 untreated CLL patients: 111 treated with B-R and 81 with Chl-R. The overall response rates (ORR; 93.6% in B-R and 86.5% in Chl-R) were not statistically different between the two groups, such as progression-free survival (PFS), time to retreatment (TTR), and overall survival (OS). The B-R group showed a higher hematological (p = 0.007) and extra-hematological (p = 0.008) toxicity. When comparing the toxicities according to age, we noted that the extra-hematological toxicity was higher in patients over the age of 75 who were treated with B-R than those treated with Chl-R (p = 0.03). This retrospective study confirms the feasibility of B-R and Chl-R in elderly untreated CLL patients. Currently, patients who are over 75 and unfit are usually treated with Chl-R. This scheme allows achieving the same ORR, PFS, TTR, and OS when compared with B-R because of hematological and extra-hematological toxicities due to B, in which a greater dose reduction has been shown in comparison to Chl.
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Affiliation(s)
- Francesco Autore
- Institute of Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Idanna Innocenti
- Institute of Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Corrente
- Institute of Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Maria Ilaria Del Principe
- Hematology Unit, Department of Biomedicine and Prevention, University tor Vergata of Rome, Rome, Italy
| | - Serena Rosati
- Hematology Unit, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Paolo Falcucci
- Division of Hematology, Ospedale Belcolle, Viterbo, Italy
| | - Alberto Fresa
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Esmeralda Conte
- Hematology Unit, Azienda Ospedaliera-Universitaria Sant'Andrea, Rome, Italy
| | | | - Daniela Renzi
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Laura De Padua
- Hematology Unit, Fabrizio Spaziani Hospital, Frosinone, Italy
| | | | - Francesco Pisani
- Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Cimino
- Hematology Unit, Ospedale Santa Maria Goretti, Latina, Italy
| | - Agostino Tafuri
- Hematology Unit, Azienda Ospedaliera-Universitaria Sant'Andrea, Rome, Italy
| | | | - Francesca Romana Mauro
- Hematology Unit, Department of Cellular Biotechnologies and Hematology, Sapienza University, Rome, Italy
| | - Giovanni Del Poeta
- Hematology Unit, Department of Biomedicine and Prevention, University tor Vergata of Rome, Rome, Italy
| | - Luca Laurenti
- Institute of Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
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Rotbain EC, Frederiksen H, Hjalgrim H, Rostgaard K, Egholm GJ, Zahedi B, Poulsen CB, Enggard L, da Cunha-Bang C, Niemann CU. IGHV mutational status and outcome for patients with chronic lymphocytic leukemia upon treatment: a Danish nationwide population-based study. Haematologica 2019; 105:1621-1629. [PMID: 31582540 PMCID: PMC7271602 DOI: 10.3324/haematol.2019.220194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 09/26/2019] [Indexed: 01/23/2023] Open
Abstract
Patients with chronic lymphocytic leukemia and unmutated immunoglobulin heavy-chain variable region gene (IGHV) have inferior survival from time of treatment in clinical studies. We assessed real-world outcomes based on mutational status and treatment regimen in a nationwide population-based cohort, comprising all 4,135 patients from the Danish chronic lymphocytic leukemia registry diagnosed between 2008 and 2017. In total, 850 patients with known mutational status received treatment: 42% of patients received intensive chemoimmunotherapy consisting of fludarabine, cyclophosphamide plus rituximab, or bendamustine plus rituximab; 27% received chlorambucil in combination with anti-CD20 antibodies or as monotherapy, and 31% received other, less common treatments. No difference in overall survival from time of first treatment according to mutational status was observed, while treatment-free survival from start of first treatment was inferior for patients with unmutated IGHV. The median treatment-free survival was 2.5 years for patients treated with chlorambucil plus anti-CD20, and 1 year for those who received chlorambucil monotherapy. The 3-year treatment-free survival rates for patients treated with fludarabine, cyclophosphamide plus rituximab, and bendamustine plus rituximab were 90% and 91% for those with mutated IGHV, and 76% and 53% for those with unmutated IGHV, respectively, and the 3-year overall survival rates were similar for the two regimens (86-88%). Thus, it appears that, in the real-world setting, patients progressing after intensive chemoimmunotherapy as first-line therapy can be rescued by subsequent treatment, without jeopardizing their long overall survival. Intensive chemoimmunotherapy remains a legitimate option alongside targeted agents, and part of a personalized treatment landscape in chronic lymphocytic leukemia, while improved supportive care and treatment options are warranted for unfit patients.
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Affiliation(s)
- Emelie Curovic Rotbain
- Department of Hematology, Odense University Hospital, Odense.,Department of Hematology, Rigshospitalet, Copenhagen.,Department of Clinical Research, University of Southern Denmark, Odense.,Department of Epidemiology Research, Statens Serum Institut, Copenhagen
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense.,Department of Clinical Research, University of Southern Denmark, Odense.,Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense
| | - Henrik Hjalgrim
- Department of Hematology, Rigshospitalet, Copenhagen.,Department of Epidemiology Research, Statens Serum Institut, Copenhagen
| | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen
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11
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Kabadi SM, Goyal RK, Nagar SP, Kaye JA, Davis KL. Treatment patterns, adverse events, and economic burden in a privately insured population of patients with chronic lymphocytic leukemia in the United States. Cancer Med 2019; 8:3803-3810. [PMID: 31144473 PMCID: PMC6639180 DOI: 10.1002/cam4.2268] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/08/2019] [Accepted: 05/09/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Contemporary data describing treatment patterns, adverse events (AEs), and outcomes in patients with chronic lymphocytic leukemia (CLL) in clinical practice are lacking. We conducted a retrospective cohort study and assessed treatment patterns, AEs, health-care resource use (HCRU), and costs in patients with diagnosis of CLL. METHODS Using a nationally representative population of privately insured patients in the US, adult patients with CLL diagnosis (July 2012-June 2015) were selected if they had continuous health plan enrollment for ≥12 months before the first CLL diagnosis without any evidence of any CLL-directed treatment. Treatment patterns up to four lines of therapy (LOT) and occurrence of AEs during CLL therapies were assessed. Mean per-patient monthly HCRU and costs were assessed overall and by number of unique AEs. RESULTS Of all patients meeting the selection criteria (n = 7,639; median age, 66 years), 18% (n = 1,379) received a systemic therapy during study follow-up. Of these, bendamustine/rituximab (BR) was the most common first observed regimen (28.1%), while ibrutinib was the most common therapy in the second (20.8%) and third (25.5%) observed regimens. The mean monthly all-cause and CLL-related costs, among patients treated with a systemic therapy, were $7,943 (SD = $15,757) and $5,185 (SD = $9,935), respectively. Mean monthly all-cause costs increased by the number of AEs (from $905 [SD = $1,865] among those with no AEs to $6,032 [SD = $13,290] among those with ≥6 AEs). CONCLUSIONS Chemoimmunotherapy, particularly BR, was the most common first observed therapy for CLL, whereas ibrutinib was most preferred in the second and third observed lines of therapy during the study period. Findings demonstrate that the economic burden of AEs in CLL is substantial.
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Affiliation(s)
| | - Ravi K Goyal
- RTI Health Solutions, Research Triangle Park, North Carolina
| | - Saurabh P Nagar
- RTI Health Solutions, Research Triangle Park, North Carolina
| | | | - Keith L Davis
- RTI Health Solutions, Research Triangle Park, North Carolina
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12
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Prospective observational study in comorbid patients with chronic lymphocytic leukemia receiving first-line bendamustine with rituximab. Leuk Res 2019; 79:17-21. [DOI: 10.1016/j.leukres.2019.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/21/2022]
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13
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Iannitto E, Bellei M, Amorim S, Ferreri AJM, Marcheselli L, Cesaretti M, Haioun C, Mancuso S, Bouabdallah K, Gressin R, Tripodo C, Traverse‐Glehen A, Baseggio L, Zupo S, Stelitano C, Castagnari B, Patti C, Alvarez I, Liberati AM, Merli M, Gini G, Cabras MG, Dupuis J, Tessoulin B, Perrot A, Re F, Palombi F, Gulino A, Zucca E, Federico M, Thieblemont C. Efficacy of bendamustine and rituximab in splenic marginal zone lymphoma: results from the phase II BRISMA/IELSG36 study. Br J Haematol 2018; 183:755-765. [DOI: 10.1111/bjh.15641] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Emilio Iannitto
- Department of Oncology ‐ Haematology Unit AOU Policlinico P. Giaccone Palermo Italy
| | - Monica Bellei
- Fondazione Italiana Linfomi (FIL) c/o Department of Diagnostic, Clinical and Public Health Medicine University of Modena and Reggio Emilia Modena Italy
| | - Sandy Amorim
- APHP, Saint‐Louis Hospital Haemato‐Oncology Paris France
| | | | - Luigi Marcheselli
- Fondazione Italiana Linfomi (FIL) c/o Department of Diagnostic, Clinical and Public Health Medicine University of Modena and Reggio Emilia Modena Italy
| | - Marina Cesaretti
- Fondazione Italiana Linfomi (FIL) c/o Department of Diagnostic, Clinical and Public Health Medicine University of Modena and Reggio Emilia Modena Italy
| | - Corinne Haioun
- Lymphoid Malignancies Unit University Hospital Henri Mondor Creteil France
| | - Salvatrice Mancuso
- Department of Oncology ‐ Haematology Unit AOU Policlinico P. Giaccone Palermo Italy
| | | | - Remy Gressin
- Onco‐Haematology Department University Hospital Grenoble Grenoble France
- INSERM, U823 Génétique et Epigenetique des cancers lymphoïdes Institut Albert Bonniot Grenoble France
| | - Claudio Tripodo
- Tumour Immunology Unit Human Pathology Section Department of Health Science University of Palermo Palermo Italy
| | | | - Lucile Baseggio
- Centre Hospitalier Lyon Sud Laboratoire d'Hématologie cellulaire Université Lyon 1 Pierre Benite France
| | - Simonetta Zupo
- Molecular Diagnostic Unit Policlinico San Martino Genova Italy
| | - Caterina Stelitano
- Division of Haematology Azienda Ospedaliera Bianchi‐Melacrino‐Morelli Reggio Calabria Italy
| | | | - Caterina Patti
- Division of Haematology Azienda Ospedali Riuniti Villa Sofia‐Cervello Palermo Italy
| | - Isabel Alvarez
- Arcispedale Santa Maria Nuova UOC of Haematology AUSL Reggio Emilia/IRCCS Reggio Emilia Italy
| | - Anna Marina Liberati
- Santa Maria Hospital Oncology‐Haematology Perugia University of Perugia Perugia Italy
| | - Michele Merli
- University Hospital Ospedale di Circolo e Fondazione Macchi ASST Settelaghi Varese Italy
| | - Guido Gini
- Division of Haematology Ospedali Riuniti Ancona Italy
| | | | - Jean Dupuis
- Lymphoid Malignancies Unit Henri Mondor Hospital Creteil France
| | - Benoit Tessoulin
- Department of Clinical Haematology Nantes University Hospital Nantes France
| | - Aurore Perrot
- Haematology Department University Hospital Vandoeuvre Les Nancy France
| | - Francesca Re
- Azienda Ospedaliero‐Universitaria di Parma UO Ematologia e CTMO Parma Italy
| | - Francesca Palombi
- Haematology and Stem Cell Transplant Regina Elena National Cancer Institute Rome Italy
| | - Alessandro Gulino
- Tumour Immunology Unit Human Pathology Section Department of Health Science University of Palermo Palermo Italy
| | - Emanuele Zucca
- IOSI, Oncology Institute of Southern Switzerland and IOR Institute of Oncology Research Università della Svizzera Italiana (USI) Bellinzona Switzerland
| | - Massimo Federico
- Department of Diagnostic, Clinical, and Public Health Medicine University of Modena and Reggio Emilia Modena Italy
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Nightingale G, Schwartz R, Kachur E, Dixon BN, Cote C, Barlow A, Barlow B, Medina P. Clinical pharmacology of oncology agents in older adults: A comprehensive review of how chronologic and functional age can influence treatment-related effects. J Geriatr Oncol 2018; 10:4-30. [PMID: 30017734 DOI: 10.1016/j.jgo.2018.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/11/2018] [Accepted: 06/19/2018] [Indexed: 12/22/2022]
Abstract
Unique challenges exist when managing older adults with cancer. Associations between cancer and age-related physiologic changes have a direct impact on pharmacokinetics and pharmacodynamics of cancer therapies and can affect drug dosing, dose intensity, efficacy, safety and quality of life. The breadth and depth of these issues, however, have not been fully evaluated because the majority of clinical trials have focused on a younger and healthier population. As a consequence, little information is available to support clinicians in making evidence-based decisions regarding treatment with cancer therapies in older adults, especially those over age 75. Prior clinical pharmacology reviews summarized the literature on how age-related physiologic changes can influence and affect conventional and targeted anti-cancer treatments. Our article provides an updated review with expanded information that includes small molecule kinase inhibitors, monoclonal antibodies, immunotherapies, hormonal, conventional, and miscellaneous agents. Additionally, our article integrates how functional age, determined by the geriatric assessment (GA), can also influence treatment-related effects and health outcomes. Broadening cancer therapy trials to capture not only chronologic age but also functional age would allow clinicians to better identify subsets of older adults who benefit from treatment versus those most vulnerable to morbidity and/or mortality.
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Affiliation(s)
- Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Rowena Schwartz
- Pharmacy Practice, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, United States
| | - Ekaterina Kachur
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, United States
| | - Brianne N Dixon
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | - Ashley Barlow
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, United States
| | - Brooke Barlow
- Department of Pharmacy Practice, Jefferson College of Pharmacy, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Medina
- Director of Pharmacy, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, United States
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15
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Affiliation(s)
- A Cuneo
- Department of Radiotherapy, Hematology Unit, University of Ferrara, Ferrara
| | - R Foà
- Department of Cellular Biotechnologies and Hematology, Policlinico Umberto I, Sapienza University, Rome, Italy
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16
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Michallet AS, Aktan M, Hiddemann W, Ilhan O, Johansson P, Laribi K, Meddeb B, Moreno C, Raposo J, Schuh A, Ünal A, Widenius T, Bernhardt A, Kellershohn K, Messeri D, Osborne S, Leblond V. Rituximab plus bendamustine or chlorambucil for chronic lymphocytic leukemia: primary analysis of the randomized, open-label MABLE study. Haematologica 2018; 103:698-706. [PMID: 29419437 PMCID: PMC5865431 DOI: 10.3324/haematol.2017.170480] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/22/2018] [Indexed: 11/11/2022] Open
Abstract
MABLE investigated the efficacy and safety of rituximab plus bendamustine or rituximab plus chlorambucil in fludarabine-ineligible patients with chronic lymphocytic leukemia. Patients received rituximab plus bendamustine or rituximab plus chlorambucil every four weeks for six cycles. Rituximab plus chlorambucil-treated patients without a complete response after Cycle 6 received chlorambucil monotherapy for at least six additional cycles or until complete response. The primary endpoint was complete response rate (confirmed by bone marrow biopsy) after Cycle 6 in first-line patients. Secondary endpoints included progression-free survival, overall survival, minimal residual disease, and safety. Overall, 357 patients were randomized (rituximab plus bendamustine, n=178; rituximab plus chlorambucil, n=179; intent-to-treat population), including 241 first-line patients (n=121 and n=120, respectively); 355 patients received treatment (n=177 and n=178, respectively; safety population). In first-line patients, complete response rate after Cycle 6 (rituximab plus bendamustine, 24%; rituximab plus chlorambucil, 9%; P=0.002) and median progression-free survival (rituximab plus bendamustine, 40 months; rituximab plus chlorambucil, 30 months; P=0.003) were higher with rituximab plus bendamustine than rituximab plus chlorambucil. Overall response rate and overall survival were not different. In first-line patients with a complete response, minimal residual disease-negativity was higher with rituximab plus bendamustine than rituximab plus chlorambucil (66% vs. 36%). Overall adverse event incidence was similar (rituximab plus bendamustine, 98%; rituximab plus chlorambucil, 97%). Rituximab plus bendamustine may be a valuable first-line option for fludarabine-ineligible patients with chronic lymphocytic leukemia.
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Affiliation(s)
| | - Melih Aktan
- Istanbul Medical Faculty, Istanbul University, Turkey
| | - Wolfgang Hiddemann
- Department of Internal Medicine III, Ludwig-Maximilians University of Munich, Germany
| | - Osman Ilhan
- Department of Hematology, Ankara University School of Medicine, Turkey
| | | | - Kamel Laribi
- Department of Hematology, Centre Hospitalier du Mans, Le Mans, France
| | - Balkis Meddeb
- Hematology Department, Aziza Othmana University Hospital, Tunis, Tunisia
| | - Carol Moreno
- Department of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - João Raposo
- Hematology Service, Hospital de Santa Maria, Lisbon, Portugal
| | - Anna Schuh
- Department of Oncology, Oxford University Hospitals, UK
| | - Ali Ünal
- Department of Hematology, Erciyes University Medical School, Kayseri, Turkey
| | - Tom Widenius
- Department of Internal Medicine, Peijas Hospital, Vantaa, Finland
| | - Alf Bernhardt
- Product Development Medical Affairs, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | | | - Dimitri Messeri
- Product Development Medical Affairs, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Stuart Osborne
- Product Development Medical Affairs, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Véronique Leblond
- Clinical Hematology, AP-HP Hôpital Pitié-Salpêtrière, UPMC University, Paris, France
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17
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Innocenti I, Autore F, Pasquale R, Morelli F, Efremov DG, Laurenti L. Treatment approach for elderly and unfit patients with chronic lymphocytic leukemia. Expert Rev Hematol 2017; 10:1069-1076. [DOI: 10.1080/17474086.2017.1398642] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Idanna Innocenti
- Institute of Hematology Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesco Autore
- Institute of Hematology Università Cattolica del Sacro Cuore, Roma, Italy
| | - Raffaella Pasquale
- Institute of Hematology Università Cattolica del Sacro Cuore, Roma, Italy
| | - Francesca Morelli
- Institute of Hematology Università Cattolica del Sacro Cuore, Roma, Italy
| | - Dimitar G Efremov
- International Centre For Genetic Engineering and Biotechnology, Trieste, Italy
| | - Luca Laurenti
- Institute of Hematology Università Cattolica del Sacro Cuore, Roma, Italy
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18
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Poropatich K, Fontanarosa J, Samant S, Sosman JA, Zhang B. Cancer Immunotherapies: Are They as Effective in the Elderly? Drugs Aging 2017; 34:567-581. [DOI: 10.1007/s40266-017-0479-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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Molica S. Targeted therapy in the treatment of chronic lymphocytic leukemia: facts, shortcomings and hopes for the future. Expert Rev Hematol 2017; 10:425-432. [DOI: 10.1080/17474086.2017.1313108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Stefano Molica
- Department of Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
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20
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Al-Sawaf O, Cramer P, Goede V, Hallek M, Pflug N. Bendamustine and its role in the treatment of unfit patients with chronic lymphocytic leukaemia: a perspective review. Ther Adv Hematol 2017; 8:197-205. [PMID: 28567239 DOI: 10.1177/2040620717699365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
With a median age of 72 years at first diagnosis, chronic lymphocytic leukaemia (CLL) is a disease of the elderly. At this age, many patients cannot bear an intensive chemoimmunotherapy like fludarabine, cyclophosphamide and rituximab (FCR), and therapeutic decisions are commonly complicated by a high burden of accompanying comorbidities. Clinical trials, on the other hand, are mostly designed to include a far healthier and younger trial population, with a median age in most studies well below 70 years, leading to an insufficient reflection of clinical reality. With the introduction of new targeted therapies, treatment of CLL is currently undergoing a profound change. New compounds like ibrutinib or idelalisib have enlarged the therapeutic options in treating CLL. However, so far, these oral medications imply continuous intake by the patient, which will at some point lead to the issue of adherence in most patients. In addition, long-term experiences are largely missing. In this setting, one of the oldest chemoactive substances remains a viable option for many CLL patients and their treating physicians: bendamustine, a nitrogen-mustard derivative, has proven to be a safe and efficient agent for treatment of CLL in the first- and second-line setting. In particular, there is some evidence that the substance is relatively well tolerated in elderly and unfit patients. In this review, we summarize the current data on bendamustine in the treatment of elderly and unfit patients with CLL and aim to provide a concise analysis and outlook on the current and future role of this substance in the era of new targeted agents.
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Affiliation(s)
- Othman Al-Sawaf
- 1st Department of Internal Medicine and Centre for Integrated Oncology CIO Köln/Bonn, University Hospital of Cologne, Cologne, Germany German CLL Study Group (GCLLSG), Cologne, Germany
| | - Paula Cramer
- 1st Department of Internal Medicine and Centre for Integrated Oncology CIO Köln/Bonn, University Hospital of Cologne, Cologne, Germany German CLL Study Group (GCLLSG), Cologne, Germany
| | | | - Michael Hallek
- 1st Department of Internal Medicine and Centre for Integrated Oncology CIO Köln/Bonn, University Hospital of Cologne, Cologne, Germany German CLL Study Group (GCLLSG), Cologne, Germany
| | - Natali Pflug
- Klinik I für Innere Medizin, Kerpener Straße 62, 50937 Köln, Germany
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21
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Ogawa Y, Izutsu K, Kiguchi T, Choi I, Takatsuka Y, Ando K, Suzumiya J. A multicenter, single-arm, Phase II clinical trial of bendamustine monotherapy in patients with chronic lymphocytic leukemia in Japan. Int J Hematol 2017; 105:631-637. [DOI: 10.1007/s12185-016-2178-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/27/2016] [Accepted: 12/27/2016] [Indexed: 12/22/2022]
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22
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Bendamustine added to allogeneic conditioning improves long-term outcomes in patients with CLL. Bone Marrow Transplant 2016; 52:28-33. [PMID: 27595282 DOI: 10.1038/bmt.2016.204] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/14/2016] [Accepted: 07/02/2016] [Indexed: 11/08/2022]
Abstract
Bendamustine has shown a favorable safety profile when included in chemotherapy regimens for several types of lymphoma, including CLL. This study investigated the long-term effect of adding bendamustine to a conditioning regimen on survival, rate of engraftment, immune recovery and GvHD after allogeneic stem cell transplantation (alloSCT) in CLL patients. These outcomes were compared with the fludarabine, cyclophosphamide and rituximab (FCR) conditioning regimen. We reviewed the data for 89 CLL patients treated on three trials at our institution. Twenty-six (29%) patients received bendamustine, fludarabine and rituximab (BFR) and 63 (71%) received FCR. Patient characteristics were similar in both groups. Ten (38%) BFR-treated patients vs only two (3%) FCR-treated patients did not experience severe neutropenia (P=<0.001). The 3-year overall survival estimates for the BFR and FCR groups were 82 and 51% (P=0.03), and the 3-year PFS estimates were 63% and 27% (P=0.001), respectively. The 2-year treatment-related mortality was 8 and 23% and the incidence of grade 3 or 4 GvHD was 4% and 10%, respectively. This study is the first to report that addition of bendamustine to alloSCT conditioning for CLL patients is associated with improved survival and lower mortality, myelosuppression, and GvHD.
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23
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Frustaci AM, Tedeschi A, Picardi P, Mazzucchelli M, Cairoli R, Montillo M. Ofatumumab plus chlorambucil as a first-line therapy in less fit patients with chronic lymphocytic leukemia: analysis of COMPLEMENT1 and other monoclonal antibodies association data. Ther Adv Hematol 2016; 7:222-30. [PMID: 27493712 DOI: 10.1177/2040620716648567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The management of patients with chronic lymphocytic leukemia (CLL) has radically improved over the last few years with the addition of anti-CD20 monoclonal antibodies (MoAbs) to chemotherapy. Chlorambucil has been considered for decades as a suitable therapeutic option for frail patients. Taking into account the advantage offered by the addition of MoAbs to chemotherapy, different studies up to now have explored the feasibility of chlorambucil-based chemoimmunotherapies in treatment-naïve CLL. COMPLEMENT1 is a prospective, randomized, open-label trial evaluating the efficacy and safety of ofatumumab added to chlorambucil, compared with chlorambucil in monotherapy, in the setting of untreated patients with CLL considered unsuitable for a fludarabine-based approach. Progression-free survival was significantly longer in the chemoimmunotherapy arm when compared with the single-agent chlorambucil (22.4 months versus 13.1 months). Response rate and quality were also improved in the combination arm. Furthermore, the addition of ofatumumab did not lead to an unmanageable toxicity. While the employment of anti-CD20 antibodies represents an advantage in the treatment of the CLL symptomatic population, at present different patient selection and treatment schedules do not allow a reliable comparison between chlorambucil-based regimens. The addition of ofatumumab to chlorambucil represents a further therapeutic gain in CLL. Longer follow up and direct comparison with other MoAbs are warranted to establish the preferred first-line treatment in elderly and unfit patients.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | | | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Milan, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
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24
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First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol 2016; 17:928-942. [PMID: 27216274 DOI: 10.1016/s1470-2045(16)30051-1] [Citation(s) in RCA: 435] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/09/2016] [Accepted: 03/29/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab is the standard therapy for physically fit patients with advanced chronic lymphocytic leukaemia. This international phase 3 study compared the efficacy and tolerance of the standard therapy with a potentially less toxic combination consisting of bendamustine and rituximab. METHODS Treatment-naive fit patients with chronic lymphocytic leukaemia (aged 33-81 years) without del(17p) were enrolled after undergoing a central screening process. Patients were randomly assigned (1:1) with a computer-generated randomisation list using randomly permuted blocks with a block size of eight and were stratified according to participating country and Binet stage. Patients were allocated to receive six cycles of intravenous fludarabine (25 mg/m(2) per day) and cyclophosphamide (250 mg/m(2) per day) for the first 3 days or to intravenous bendamustine (90 mg/m(2) per day) for the first 2 days of each cycle. Rituximab 375 mg/m(2) was given intravenously in both groups on day 0 of cycle 1 and subsequently was given at 500 mg/m(2) during the next five cycles on day 1. The primary endpoint was progression-free survival with the objective to assess non-inferiority of bendamustine and rituximab to the standard therapy. We aimed to show that the 2-year progression-free survival with bendamustine and rituximab was not 67·5% or less with a corresponding non-inferiority margin of 1·388 for the hazard ratio (HR) based on the 90·4% CI. The final analysis was done by intention to treat. The study is registered with ClinicalTrials.gov, number NCT%2000769522. FINDINGS 688 patients were recruited between Oct 2, 2008, and July 11, 2011, of which 564 patients who met inclusion criteria were randomly assigned. 561 patients were included in the intention-to-treat population: 282 patients in the fludarabine, cyclophosphamide, and rituximab group and 279 in the bendamustine and rituximab group. After a median observation time of 37·1 months (IQR 31·0-45·5) median progression-free survival was 41·7 months (95% CI 34·9-45·3) with bendamustine and rituximab and 55·2 months (95% CI not evaluable) with fludarabine, cyclophosphamide, and rituximab (HR 1·643, 90·4% CI 1·308-2·064). As the upper limit of the 90·4% CI was greater than 1·388 the null hypothesis for the corresponding non-inferiority hypothesis was not rejected. Severe neutropenia and infections were more frequently observed with fludarabine, cyclophosphamide, and rituximab (235 [84%] of 279 vs 164 [59%] of 278, and 109 [39%] vs 69 [25%], respectively) during the study. The increased frequency of infectious complications with fludarabine, cyclophosphamide, and rituximab was more pronounced in patients older than 65 years. INTERPRETATION The combination of fludarabine, cyclophosphamide, and rituximab remains the standard front-line therapy in fit patients with chronic lymphocytic leukaemia, but bendamustine and rituximab is associated with less toxic effects. FUNDING Roche Pharma AG, Mundipharma, German Federal Ministry of Education and Research.
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25
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Gentile M, Zirlik K, Ciolli S, Mauro FR, Di Renzo N, Mastrullo L, Angrilli F, Molica S, Tripepi G, Giordano A, Di Raimondo F, Selleri C, Coscia M, Musso M, Orsucci L, Mannina D, Rago A, Giannotta A, Ferrara F, Herishanu Y, Shvidel L, Tadmor T, Scortechini I, Ilariucci F, Murru R, Guarini A, Musuraca G, Mineo G, Vincelli I, Arcari A, Tarantini G, Caparrotti G, Chiarenza A, Levato L, Villa MR, De Paolis MR, Zinzani PL, Polliack A, Morabito F. Combination of bendamustine and rituximab as front-line therapy for patients with chronic lymphocytic leukaemia: multicenter, retrospective clinical practice experience with 279 cases outside of controlled clinical trials. Eur J Cancer 2016; 60:154-65. [PMID: 27127905 DOI: 10.1016/j.ejca.2016.03.069] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/06/2016] [Accepted: 03/14/2016] [Indexed: 12/31/2022]
Abstract
Recently, encouraging results in terms of safety and efficacy have been obtained using bendamustine-rituximab (BR) in untreated chronic lymphocytic leukaemia (CLL) patients enrolled in a phase II study. Here, we report a retrospective international multicenter study of CLL patients treated with BR as front-line therapy. The cohort included 279 patients with progressive CLL from 33 centers (29 Italian, 3 Israeli and 1 German) who received at least 1 cycle of BR as first-line treatment during the 2008-2014 period. The primary objective of this study was to evaluate the efficacy and safety of BR administered as front-line therapy, outside of controlled clinical trials. Median age was 70 years (range, 43-86 years); 62.4% were males and 35.8% had Binet stage C. Forty-two patients (15.2%) were unfit (cumulative illness rating scale [CIRS] score ≥7), and 140 (50.2%) had creatinine clearance ≤70 ml/min. Fluorescent in situ hybridisation analysis, available for 192 cases, showed that 21 (10.9%) had del11q and 18 (9.4%) del17p. The overall response rate (ORR) was 86.4%, with a complete remission rate of 28%. Patients with del17p had an ORR of 66.7%. After median follow-up of 24 months, the 2-year progression-free survival (PFS) was 69.9%; CIRS ≥7, immunoglobulin heavy-chain variable-region (IGHV) unmutated status, del17p and BR dose intensity <80% were independently associated with shorter PFS. Grade III or IV neutropenia, thrombocytopenia, and anaemia were observed in 25.9%, 15.4%, and 15.1% of patients, respectively. Twenty-four patients (8.6%) had severe infections. BR is also an effective and safe regimen for untreated CLL patients, outside of controlled clinical trials.
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Affiliation(s)
| | - Katja Zirlik
- Department of Haematology and Oncology, University Medical Centre Freiburg, Freiburg, Germany
| | | | | | | | | | | | - Stefano Molica
- Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Giovanni Tripepi
- Consiglio Nazionale delle Ricerche, Istituto di Fisiologia Clinica, Reggio Calabria, Italy
| | - Annamaria Giordano
- Ematologia-Azienda Ospedaliero-Universitaria, Policlinico consorziale di Bari, Italy
| | - Francesco Di Raimondo
- Department of Biomedical Sciences, Division of Haematology, University of Catania and Ferrarotto Hospital, Catania, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Marta Coscia
- Division of Haematology, University of Torino, A.O. Città della Salute e della Scienza di Torino, Italy
| | - Maurizio Musso
- Hematology and Bone Marrow Transplant Unit, Dept. of Oncology, La Maddalena, Palermo, Italy
| | - Lorella Orsucci
- Division of Hematology II, San Giovanni Battista Hospital, Torino, Italy
| | - Donato Mannina
- Divisione di Ematologia, Ospedale Papardo, Messina, Italy
| | - Angela Rago
- UOC Eatologia Opedale Santa Maria Goretti, Latina, Italy
| | | | | | - Yair Herishanu
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Lev Shvidel
- Hematology Institute, Kaplan Medical Center, Rehovot, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | | | - Fiorella Ilariucci
- Hematology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Roberta Murru
- UO Ematologia e CTMO Ospedale Oncologico A. Businco, Cagliari, Italy
| | - Attilio Guarini
- Haematology Unit, National Cancer Research Centre Istituto Tumori, Bari, Italy
| | - Gerardo Musuraca
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giuseppe Mineo
- Unità di Ematologia, Ospedale San Vincenzo, Taormina, Italy
| | | | - Annalisa Arcari
- Hematology Unit, Department of Onco-Hematology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Giuseppe Caparrotti
- Department of Haematology, ASL Caserta (CE), Hospital Moscati, Aversa, CE, Italy
| | - Annalisa Chiarenza
- Department of Biomedical Sciences, Division of Haematology, University of Catania and Ferrarotto Hospital, Catania, Italy
| | - Luciano Levato
- Department of Hematology, Ospedale Santo Spirito, Pescara, Italy
| | | | | | | | - Aaron Polliack
- Department of Hematology, Hadassah University, Hospital and Hebrew University Medical School, Jerusalem, Israel
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Altered treatment of chronic lymphocytic leukemia in Germany during the last decade. Ann Hematol 2016; 95:853-61. [DOI: 10.1007/s00277-016-2640-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/09/2016] [Indexed: 11/26/2022]
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Reda G, Orofino N, Cassin R, Sciumè M, Fattizzo B, Cortelezzi A. Treating chronic lymphocytic leukemia with obinutuzumab: safety and efficacy considerations. Expert Opin Drug Saf 2016; 15:865-73. [PMID: 26967902 DOI: 10.1517/14740338.2016.1165665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Obinutuzumab is a novel glycoengineered type II anti-CD20 monoclonal antibody (MoAb) with a higher affinity for CD20 epitope. It was approved by the United States Food and Drug Administration (FDA) in November 2013 for use in combination with chlorambucil for previously untreated chronic lymphocytic leukemia (CLL). AREAS COVERED This article evaluates the safety of obinutuzumab in CLL patients, also addressing pharmacokinetics/pharmacodynamics (PK/PD), clinical use and efficacy. Moreover, a comparison with other anti-CD20 MoAb is performed. The principal available studies on obinutuzumab are reviewed, focusing on CLL. A PubMed literature search (August 2002 to September 2015) was conducted using the terms obinutuzumab, GA101, anti-CD20 antibody, and CLL. EXPERT OPINION Obinutuzumab, a third-generation anti-CD20 MoAb, is a safe and effective treatment for elderly patients who are un-fit for fludarabine-based regimen. Its use, proven in the CLL11 study and the results of many ongoing trials evaluating other obinutuzumab-based regimen can lead obinutuzumab to be a candidate to replace rituximab as the first-line treatment option.
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Affiliation(s)
- G Reda
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
| | - N Orofino
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
| | - R Cassin
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
| | - M Sciumè
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
| | - B Fattizzo
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
| | - A Cortelezzi
- a Oncohematology Department , Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milano , Italy
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Zent CS, Wang XV, Ketterling RP, Hanson CA, Libby EN, Barrientos JC, Call TG, Chang JE, Liu JJ, Calvo AR, Lazarus HM, Rowe JM, Luger SM, Litzow MR, Tallman MS. A phase II randomized trial comparing standard and low dose rituximab combined with alemtuzumab as initial treatment of progressive chronic lymphocytic leukemia in older patients: a trial of the ECOG-ACRIN cancer research group (E1908). Am J Hematol 2016; 91:308-12. [PMID: 26662208 PMCID: PMC4806550 DOI: 10.1002/ajh.24265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/28/2015] [Indexed: 12/31/2022]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) patients requiring initial therapy are often older and frailer and unsuitable candidates for standard chemoimmunotherapy regimens. Shorter duration combination monoclonal antibody (mAb) therapy using alemtuzumab and rituximab has been shown to be effective and tolerable treatment for CLL. Standard dose anti-CD20 mAb therapy causes loss of CD20 expression by surviving CLL cells, which can be minimized by decreasing the mAb dose. We report a randomized phase II clinical trial enrolling older (≥ 65 years) patients (median age 76 years, n = 31) with treatment naïve progressive CLL. Patients received 8-12 weeks of standard subcutaneous alemtuzumab with either intravenous standard (375 mg/m(2) weekly)(n = 16) or low dose (20 mg/m(2) 3x week)(n = 15) rituximab. This study was closed before full accrual because the manufacturer withdrew alemtuzumab for treatment of CLL. The overall response rate was 90% with an 45% complete response rate, median progression-free survival of 17.9 months and no significant differences in outcome between the low and standard dose rituximab arms. The major toxicities were cytopenia and infection with one treatment fatality caused by progressive multifocal leukoencephalopathy but no other opportunistic infections. Combination mAb therapy was effective and tolerable treatment for older and frailer patients with progressive CLL, achieving a high rate of complete remissions. These data support the role of mAb in therapy for less fit CLL patients and the further study of low dose higher frequency anti-CD20 mAb therapy as a potentially more effective use of anti-CD20 mAb in the treatment of CLL.
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MESH Headings
- Aged
- Aged, 80 and over
- Alemtuzumab
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Disease-Free Survival
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Rituximab/therapeutic use
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Affiliation(s)
- Clive S. Zent
- University of Rochester Medical Center, Rochester, New York (current location) Mayo Clinic, Rochester, Minnesota (former location)
| | - Xin Victoria Wang
- Dana Farber Cancer Institute – ECOG-ACRIN Biostatistics Center, Boston, Massachusetts
| | | | | | - Edward N. Libby
- Seattle Cancer Care Alliance, Seattle, Washington (current location) University of New Mexico Cancer Center, Albuquerque, NM
| | | | | | | | | | | | | | | | | | | | - Martin S. Tallman
- Memorial Sloan Kettering Cancer Center, New York, New York (current location) Northwestern University School of Medicine, Chicago, Illinois (former location)
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