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Chang JE, Wang T, Kim K, Folstad M, Endres M, Howard M, Kenkre V, Fletcher C, Rajguru S. Maintenance low-dose fixed duration lenalidomide and rituximab following bendamustine and rituximab induction in previously untreated chronic lymphocytic leukemia and small lymphocytic lymphoma. Leuk Lymphoma 2024:1-9. [PMID: 38856101 DOI: 10.1080/10428194.2024.2360535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/22/2024] [Indexed: 06/11/2024]
Abstract
Lenalidomide (LEN) and rituximab (RTX) have independently improved progression-free survival (PFS) in CLL, leading to interest in use of LEN + RTX (R2) following induction chemoimmunotherapy. Patients with previously untreated CLL received bendamustine + RTX (BR) for 6 cycles, then 24 cycles of R2. LEN dosing was 5-10 mg daily; RTX was given odd cycles (12 doses). The primary endpoint is PFS; secondary endpoints are response and overall survival. Thirty-six patients enrolled, median age 64.5 years. Twenty-nine received R2; 12 completed a full course R2 (33.3%), 5 completed R2 with premature discontinuation of LEN. Dose reductions/holds were most often for neutropenia. Complete response was achieved in 33.3%. After median >4 years follow-up, 2-year and 3-year PFS were 86.1% and 69.4%. Five-year overall survival was 92.3%. R2 maintenance may improve PFS after BR induction, and a lower dose of 5 mg/day and ≤1 year of R2 may be most tolerable (NCT00974233).
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Affiliation(s)
- Julie E Chang
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Tuo Wang
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Matthew Folstad
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Mariah Endres
- Carbone Cancer Center, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Mitch Howard
- Carbone Cancer Center, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Vaishalee Kenkre
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Christopher Fletcher
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Saurabh Rajguru
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
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Lee CH, Wu YY, Huang TC, Lin C, Zou YF, Cheng JC, Chen PH, Jhou HJ, Ho CL. Maintenance therapy for chronic lymphocytic leukaemia. Cochrane Database Syst Rev 2024; 1:CD013474. [PMID: 38174814 PMCID: PMC10765471 DOI: 10.1002/14651858.cd013474.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common lymphoproliferative disease in adults and currently remains incurable. As the progression-free period shortens after each successive treatment, strategies such as maintenance therapy are needed to improve the degree and duration of response to previous therapies. Monoclonal antibodies, immunomodulatory agents, and targeted therapies are among the available options for maintenance therapy. People with CLL who achieve remission after previous therapy may choose to undergo medical observation or maintenance therapy to deepen the response. Even though there is widespread use of therapeutic maintenance agents, the benefits and harms of these treatments are still uncertain. OBJECTIVES To assess the effects and safety of maintenance therapy, including anti-CD20 monoclonal antibody, immunomodulatory drug therapy, anti-CD52 monoclonal antibody, Bruton tyrosine kinase inhibitor, and B-cell lymphoma-2 tyrosine kinase inhibitor, for individuals with CLL. SEARCH METHODS We conducted a comprehensive literature search for randomised controlled trials (RCTs) with no language or publication status restrictions. We searched CENTRAL, MEDLINE, Embase, and three trials registers in January 2022 together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included RCTs with prospective identification of participants. We excluded cluster-randomised trials, cross-over trial designs, and non-randomised studies. We included studies comparing maintenance therapies with placebo/observation or head-to-head comparisons. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We assessed risk of bias in the included studies using Cochrane's RoB 1 tool for RCTs. We rated the certainty of evidence for the following outcomes using the GRADE approach: overall survival (OS), health-related quality of life (HRQoL), grade 3 and 4 adverse events (AEs), progression-free survival (PFS), treatment-related mortality (TRM), treatment discontinuation (TD), and all adverse events (AEs). MAIN RESULTS We identified 11 RCTs (2393 participants) that met the inclusion criteria, including seven trials comparing anti-CD20 monoclonal antibodies (mAbs) (rituximab or ofatumumab) with observation in 1679 participants; three trials comparing immunomodulatory drug (lenalidomide) with placebo/observation in 693 participants; and one trial comparing anti-CD 52 mAbs (alemtuzumab) with observation in 21 participants. No comparisons of novel small molecular inhibitors were found. The median age of participants was 54.1 to 71.7 years; 59.5% were males. The type of previous induction treatment, severity of disease, and baseline stage varied among the studies. Five trials included early-stage symptomatic patients, and three trials included advanced-stage patients (Rai stage III/IV or Binet stage B/C). Six trials reported a frequent occurrence of cytogenic aberrations at baseline (69.7% to 80.1%). The median follow-up duration was 12.4 to 73 months. The risk of selection bias in the included studies was unclear. We assessed overall risk of performance bias and detection bias as low risk for objective outcomes and high risk for subjective outcomes. Overall risk of attrition bias, reporting bias, and other bias was low. Anti-CD20 monoclonal antibodies (mAbs): rituximab or ofatumumab maintenance versus observation Anti-CD20 mAbs maintenance likely results in little to no difference in OS (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.73 to 1.20; 1152 participants; 3 studies; moderate-certainty evidence) and likely increases PFS significantly (HR 0.61, 95% CI 0.50 to 0.73; 1255 participants; 5 studies; moderate-certainty evidence) compared to observation alone. Anti-CD20 mAbs may result in: an increase in grade 3/4 AEs (rate ratio 1.34, 95% CI 1.06 to 1.71; 1284 participants; 5 studies; low-certainty evidence); little to no difference in TRM (risk ratio 0.82, 95% CI 0.39 to 1.71; 1189 participants; 4 studies; low-certainty evidence); a slight reduction to no difference in TD (risk ratio 0.93, 95% CI 0.72 to 1.20; 1321 participants; 6 studies; low-certainty evidence); and an increase in all AEs (rate ratio 1.23, 95% CI 1.03 to 1.47; 1321 participants; 6 studies; low-certainty evidence) compared to the observation group. One RCT reported that there may be no difference in HRQoL between the anti-CD20 mAbs (ofatumumab) maintenance and the observation group (mean difference -1.70, 95% CI -8.59 to 5.19; 480 participants; 1 study; low-certainty evidence). Immunomodulatory drug (IMiD): lenalidomide maintenance versus placebo/observation IMiD maintenance therapy likely results in little to no difference in OS (HR 0.91, 95% CI 0.61 to 1.35; 461 participants; 3 studies; moderate-certainty evidence) and likely results in a large increase in PFS (HR 0.37, 95% CI 0.19 to 0.73; 461 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. Regarding harms, IMiD maintenance therapy may result in an increase in grade 3/4 AEs (rate ratio 1.82, 95% CI 1.38 to 2.38; 400 participants; 2 studies; low-certainty evidence) and may result in a slight increase in TRM (risk ratio 1.22, 95% CI 0.35 to 4.29; 458 participants; 3 studies; low-certainty evidence) compared to placebo/observation. The evidence for the effect on TD compared to placebo is very uncertain (risk ratio 0.71, 95% CI 0.47 to 1.05; 400 participants; 2 studies; very low-certainty evidence). IMiD maintenance therapy probably increases all AEs slightly (rate ratio 1.41, 95% CI 1.28 to 1.54; 458 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. No studies assessed HRQoL. Anti-CD52 monoclonal antibodies (mAbs): alemtuzumab maintenance versus observation Maintenance with alemtuzumab may have little to no effect on PFS, but the evidence is very uncertain (HR 0.55, 95% CI 0.32 to 0.95; 21 participants; 1 study; very low-certainty evidence). We did not identify any study reporting the outcomes OS, HRQoL, grade 3/4 AEs, TRM, TD, or all AEs. AUTHORS' CONCLUSIONS There is currently moderate- to very low-certainty evidence available regarding the benefits and harms of maintenance therapy in people with CLL. Anti-CD20 mAbs maintenance improved PFS, but also increased grade 3/4 AEs and all AEs. IMiD maintenance had a large effect on PFS, but also increased grade 3/4 AEs. However, none of the above-mentioned maintenance interventions show differences in OS between the maintenance and control groups. The effects of alemtuzumab maintenance are uncertain, coupled with a warning for drug-related infectious toxicity. We found no studies evaluating other novel maintenance interventions, such as B-cell receptor inhibitors, B-cell leukaemia-2/lymphoma-2 inhibitors, or obinutuzumab.
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Affiliation(s)
- Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ying Wu
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chuan Huang
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Fen Zou
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ju-Chun Cheng
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Rios-Olais FA, Hilal T. Measurable Residual Disease in Chronic Lymphocytic Leukemia: Current Understanding and Evolving Role in Clinical Practice. Curr Treat Options Oncol 2023:10.1007/s11864-023-01103-1. [PMID: 37195588 DOI: 10.1007/s11864-023-01103-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
OPINION STATEMENT Treatment of chronic lymphocytic leukemia (CLL) has evolved dramatically during the last decade, from chemoimmunotherapy (CIT)-based therapies to newer B-cell receptor (BCR) signaling targeting agents, which are sometimes given as continuous schemes. Response to treatment was traditionally defined according to clinical variables designed to assign a response category. Interest in assessing for deeper responses in CLL by the means of measurable residual disease (MRD) testing has been the subject of research during the last several years. Analyses and sub-analyses of clinical trials have shown that achieving undetectable MRD (uMRD) in CLL is an important prognostic factor. In this review, we summarize the available evidence about MRD in CLL, from the various assays available for measurement, the compartment to test, the impact of reaching uMRD according to the treatment regimen, and the results of fixed duration treatment guided by MRD trials. Finally, we summarize how MRD can be incorporated in clinical practice and how it may guide fixed duration treatment in the future should evidence continue to accumulate in that direction.
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Affiliation(s)
| | - Talal Hilal
- Mayo Clinic, 5777 E. Mayo Boulevard, Phoenix, AZ, 85054, USA.
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Jolles S, Giralt S, Kerre T, Lazarus HM, Mustafa SS, Ria R, Vinh DC. Agents contributing to secondary immunodeficiency development in patients with multiple myeloma, chronic lymphocytic leukemia and non-Hodgkin lymphoma: A systematic literature review. Front Oncol 2023; 13:1098326. [PMID: 36824125 PMCID: PMC9941665 DOI: 10.3389/fonc.2023.1098326] [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: 11/14/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Abstract
Introduction Patients with hematological malignancies (HMs), like chronic lymphocytic leukemia (CLL), multiple myeloma (MM), and non-Hodgkin lymphoma (NHL), have a high risk of secondary immunodeficiency (SID), SID-related infections, and mortality. Here, we report the results of a systematic literature review on the potential association of various cancer regimens with infection rates, neutropenia, lymphocytopenia, or hypogammaglobulinemia, indicative of SID. Methods A systematic literature search was performed in 03/2022 using PubMed to search for clinical trials that mentioned in the title and/or abstract selected cancer (CLL, MM, or NHL) treatments covering 12 classes of drugs, including B-lineage monoclonal antibodies, CAR T therapies, proteasome inhibitors, kinase inhibitors, immunomodulators, antimetabolites, anti-tumor antibiotics, alkylating agents, Bcl-2 antagonists, histone deacetylase inhibitors, vinca alkaloids, and selective inhibitors of nuclear export. To be included, a publication had to report at least one of the following: percentages of patients with any grade and/or grade ≥3 infections, any grade and/or grade ≥3 neutropenia, or hypogammaglobulinemia. From the relevant publications, the percentages of patients with lymphocytopenia and specific types of infection (fungal, viral, bacterial, respiratory [upper or lower respiratory tract], bronchitis, pneumonia, urinary tract infection, skin, gastrointestinal, and sepsis) were collected. Results Of 89 relevant studies, 17, 38, and 34 included patients with CLL, MM, and NHL, respectively. In CLL, MM, and NHL, any grade infections were seen in 51.3%, 35.9% and 31.1% of patients, and any grade neutropenia in 36.3%, 36.4%, and 35.4% of patients, respectively. The highest proportion of patients with grade ≥3 infections across classes of drugs were: 41.0% in patients with MM treated with a B-lineage monoclonal antibody combination; and 29.9% and 38.0% of patients with CLL and NHL treated with a kinase inhibitor combination, respectively. In the limited studies, the mean percentage of patients with lymphocytopenia was 1.9%, 11.9%, and 38.6% in CLL, MM, and NHL, respectively. Two studies reported the proportion of patients with hypogammaglobulinemia: 0-15.3% in CLL and 5.9% in NHL (no studies reported hypogammaglobulinemia in MM). Conclusion This review highlights cancer treatments contributing to infections and neutropenia, potentially related to SID, and shows underreporting of hypogammaglobulinemia and lymphocytopenia before and during HM therapies.
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Affiliation(s)
- Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom,*Correspondence: Stephen Jolles,
| | - Sergio Giralt
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Tessa Kerre
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Hillard M. Lazarus
- Department of Medicine, Hematology-Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S. Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States,Department of Medicine, Allergy/Immunology and Rheumatology, University of Rochester, Rochester, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C. Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
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5
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Kutsch N, Holmes EE, Robrecht S, Schüler G, Vehling-Kaiser U, Decker T, Müller-Hagen S, Heinisch K, Böttcher S, Ritgen M, Kreuzer KA, Stilgenbauer S, Fink AM, Fischer K, Eichhorst B, Hallek M, Wendtner CM. Efficacy and safety of obinutuzumab combined with fludarabine and cyclophosphamide (FCG) or bendamustine (BG) in relapsed or refractory CLL patients followed by maintenance therapy with obinutuzumab for responding patients. Leuk Lymphoma 2023; 64:478-482. [PMID: 36423347 DOI: 10.1080/10428194.2022.2148210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Emily Eva Holmes
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Gudrun Schüler
- Praxis für Hämatologie und Onkologie Cottbus, Cottbus, Germany
| | | | | | - Sigrun Müller-Hagen
- Onkologie und Palliativmedizin Hamburg, Praxis für Hämatologie, Hamburg, Germany
| | | | - Sebastian Böttcher
- Medizinische Klinik III, University Hospital of Rostock, Rostock, Germany
| | - Matthias Ritgen
- Innere Medizin III, University Hospital Schleswig Holstein, Kiel, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Stephan Stilgenbauer
- Division of CLL, Klinik für Innere Medizin III, University Hospital Ulm, Ulm, Germany
| | - Anna Maria Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Clemens-Martin Wendtner
- Munich Clinic Schwabing, Academic Teaching Hospital, Ludwig-Maximilian University (LMU), Munich, Germany
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Mkhwanazi ZA, Nyambuya TM, Mfusi SA, Nkambule BB. Prognostic markers in patients with chronic lymphocytic leukaemia on targeted therapy, chemoimmunotherapy with anti-CD20 monoclonal antibody: a systematic review and meta-analysis of prognostic factors. BMC Cancer 2022; 22:1218. [PMID: 36434612 PMCID: PMC9701011 DOI: 10.1186/s12885-022-10223-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 10/04/2022] [Indexed: 11/27/2022] Open
Abstract
Combination chemoimmunotherapy (CIT) consisting of anti-CD20 has improved the progression-free survival (PFS) and overall survival (OS) of patients with chronic lymphocytic leukaemia (CLL). We performed a comprehensive synthesis of prognostic factors in patients with CLL on combined CIT with anti-CD20 antibodies compared with standard chemotherapy alone or targeted therapy.We searched the MEDLINE and academic search complete electronic databases as well as clinicaltrials.gov (from inception up to 01 August 2022) for randomised controlled trials examining chemoimmunotherapy and targeted therapy in patients with CLL. The risk of bias and the quality of evidence was assessed using the quality in prognostic studies tool (QUIPS).A total of 10 prognostic factors were identified and evaluated in patients with CLL on anti-CD20 antibody-containing CIT. The predictive value of the following prognostic factors was confirmed and associated with poor patient outcomes; deletion 17p (HR = 3.39), Immunoglobulin heavy chain variable region gene mutation status (HR = 0.96) and β2-microglobulin (HR = 1.41).Conventional predictive factors may have retained prognostic value and could be useful in the stratification of patients who may be non-responsive to CIT.Trial registration: International Prospective Register of Systematic Reviews (PROSPERO) registry (CRD42021218997).
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Affiliation(s)
- Zekhethelo A. Mkhwanazi
- grid.16463.360000 0001 0723 4123School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Tawanda M. Nyambuya
- grid.442466.60000 0000 8752 9062Department of Health Sciences, Faculty of Health and Applied Sciences, Namibia University of Science and Technology, Windhoek, Namibia
| | - Snenhlanhla A. Mfusi
- grid.16463.360000 0001 0723 4123School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Bongani B. Nkambule
- grid.16463.360000 0001 0723 4123School of Laboratory Medicine and Medical Sciences (SLMMS), College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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7
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Vassilopoulos S, Shehadeh F, Kalligeros M, Tran QL, Schiffman F, Mylonakis E. Targeted therapies in CLL/SLL and the cumulative incidence of infection: A systematic review and meta-analysis. Front Pharmacol 2022; 13:989830. [PMID: 36188587 PMCID: PMC9515578 DOI: 10.3389/fphar.2022.989830] [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: 07/08/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) are prone to infections. Aims: Provide a pooled estimate of the cumulative incidence for infections that fulfilled the criteria associated with severe infectious adverse events for grade 3 or higher (including pneumonia, febrile neutropenia and sepsis) in patients who receive targeted therapies. Methods: We searched PubMed and EMBASE for randomized controlled trials (RCT) that included patients with CLL/SLL who received targeted therapies and performed a random-effects meta-analysis to estimate the cumulative incidence of infections. Results: Of 2,914 studies screened, we retrieved 31 which evaluated 11,660 patients. The pooled cumulative incidence of infections for patients who received treatment regimens based on a BTK inhibitors was 19.86%. For patients who received treatment based on rituximab and second generation anti-CD20 monoclonal antibodies, the pooled cumulative incidence of infections was 19.85 and 13.46%, respectively. Regarding PI3K inhibitor-based regimens the cumulative incidence of severe infections was 30.89%. BCL-2 inhibitors had a cumulative incidence of infections of 17.49% while lenalidomide and alemtuzumab had an incidence of 13.33 and 45.09%, respectively. The cumulative incidence of pneumonia ranged from 3.01 to 8.45% while febrile neutropenia ranged from 2.68 to 10.80%. Regarding sepsis, the cumulative incidence ranged from 0.9 to 4.48%. Conclusion: Patients with CLL/SLL who receive targeted therapies may develop severe infections at significant rates that, in addition to disease stage and other complications, depend on the mechanism of action of the used drug. Surveillance for infections and development of effective prophylactic strategies are critical for patients with CLL/SLL who receive targeted therapies. Systematic Review Registration: [https://systematicreview.gov/], identifier [registration number]
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Affiliation(s)
- Stephanos Vassilopoulos
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Fadi Shehadeh
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- School of Electrical and Computer Engineering, National Technical University of Athens, Athens, Greece
| | - Markos Kalligeros
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Quynh-Lam Tran
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Fred Schiffman
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- Division of Hematology-Oncology, Rhode Island Hospital and The Miriam Hospital, Providence, RI, United States
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Rhode Island Hospital, Providence, RI, United States
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- *Correspondence: Eleftherios Mylonakis,
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8
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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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9
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Desai S, Mo C, Gaglione EM, Yuan CM, Stetler-Stevenson M, Tian X, Maric I, Wake L, Farooqui MZ, Drinkwater DC, Soto S, Valdez J, Hughes TE, Nierman P, Lotter J, Marti GE, Pleyer C, Sun C, Superata J, Nichols C, Herman SEM, Lindorfer MA, Taylor RP, Wiestner A, Ahn IE. Risk-adapted, ofatumumab-based chemoimmunotherapy and consolidation in treatment-naïve chronic lymphocytic leukemia: a phase 2 study. Leuk Lymphoma 2021; 62:1816-1827. [PMID: 33653216 DOI: 10.1080/10428194.2021.1888379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
High-risk cytogenetics and minimal residual disease (MRD) after chemoimmunotherapy (CIT) predict unfavorable outcome in chronic lymphocytic leukemia (CLL). This phase 2 study investigated risk-adapted CIT in treatment-naïve CLL (NCT01145209). Patients with high-risk cytogenetics received induction with fludarabine, cyclophosphamide, and ofatumumab. Those without high-risk cytogenetics received fludarabine and ofatumumab. After induction, MRD positive (MRD+) patients received 4 doses of ofatumumab consolidation. MRD negative (MRD-) patients had no intervention. Of 28 evaluable for response, all responded to induction and 10 (36%) achieved MRD-. Two-year progression-free survival (PFS) was 71.4% (CI95, 56.5-90.3%). There was no significant difference in median PFS between the high-risk and the standard-risk groups. Ofatumumab consolidation didn't convert MRD + to MRD-. In the MRD + group, we saw selective loss of CD20 antigens during therapy. In conclusion, risk-adapted CIT is feasible in treatment-naïve CLL. Ofatumumab consolidation didn't improve depth of response in MRD + patients. Loss of targetable CD20 likely reduces efficacy of consolidation therapy.
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Affiliation(s)
- Sanjal Desai
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA.,Medstar Washington Hospital Center, Washington, D.C., USA
| | - Clifton Mo
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA.,Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Erika M Gaglione
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA.,Department of Biochemistry and Molecular Genetics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Constance M Yuan
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, USA
| | | | - Xin Tian
- Office of Biostatistics Research, NHLBI, NIH, Bethesda, MD, USA
| | - Irina Maric
- Department of Laboratory Medicine, Clinical Research Center, NIH, Bethesda, MD, USA
| | - Laura Wake
- Department of Laboratory Medicine, Clinical Research Center, NIH, Bethesda, MD, USA
| | - Mohammed Z Farooqui
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | | | - Susan Soto
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Janet Valdez
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Thomas E Hughes
- Department of Pharmacy, Clinical Research Center, NIH, Bethesda, MD, USA
| | - Pia Nierman
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jennifer Lotter
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Gerald E Marti
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Christopher Pleyer
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Clare Sun
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Jeanine Superata
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Cydney Nichols
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Sarah E M Herman
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Margaret A Lindorfer
- Department of Biochemistry and Molecular Genetics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ronald P Taylor
- Department of Biochemistry and Molecular Genetics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Adrian Wiestner
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Inhye E Ahn
- Hematology Branch, National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD, USA
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10
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Sharman JP, Brander DM, Mato AR, Ghosh N, Schuster SJ, Kambhampati S, Burke JM, Lansigan F, Schreeder MT, Lunin SD, Zweibach A, Shtivelband M, Travis PM, Chandler JC, Kolibaba KS, Sportelli P, Miskin HP, Weiss MS, Flinn IW. Ublituximab plus ibrutinib versus ibrutinib alone for patients with relapsed or refractory high-risk chronic lymphocytic leukaemia (GENUINE): a phase 3, multicentre, open-label, randomised trial. LANCET HAEMATOLOGY 2021; 8:e254-e266. [PMID: 33631112 DOI: 10.1016/s2352-3026(20)30433-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with chronic lymphocytic leukaemia and high-risk features have poorer outcomes on ibrutinib than those without high-risk features. The aim of this study was to assess the benefit of adding ublituximab, an anti-CD20 monoclonal antibody, to ibrutinib therapy in this population. METHODS We did a randomised, phase 3, multicentre study (GENUINE) of patients aged 18 years or older with relapsed or refractory chronic lymphocytic leukaemia with at least one of 17p deletion, 11q deletion, or TP53 mutation, at 119 clinics in the USA and Israel. Eligible patients had received at least one previous chronic lymphocytic leukaemia therapy and had an Eastern Cooperative Oncology Group performance status of 2 or lower. We randomised patients (1:1) using permuted block randomisation with a block size of four and stratified by previous lines of therapy (one vs two or more) to receive ibrutinib alone or ibrutinib in combination with ublituximab. Treatment allocation was not masked to patients or investigators. Ibrutinib was given orally daily at 420 mg for all cycles. Ublituximab was given intravenously in 28-day cycles, with increasing doses during cycle 1 (≤150 mg on day 1, 750 mg on day 2, and 900 mg on days 8 and 15) and continuing at 900 mg on day 1 of cycles 2-6. After cycle 6, ublituximab was given at 900 mg every three cycles. The study was initially designed with co-primary endpoints of progression-free survival and overall response rate but due to protracted patient accrual, the protocol was amended to have a single primary endpoint of independent review committee-assessed overall response rate (defined as the proportion of patients who had a partial response, complete response, or complete response with incomplete marrow recovery according to the 2008 International Workshop on CLL criteria) in the intention-to-treat population. Safety was evaluated in the population of patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov, NCT02301156, and the final analysis is presented. FINDINGS 224 patients were assessed for eligibility, of whom 126 patients were enrolled and randomly assigned to receive ublituximab plus ibrutinib (n=64) or ibrutinib alone (n=62) between Feb 6, 2015, and Dec 19, 2016. After a median follow-up of 41·6 months (IQR 36·7-47·3), the overall response rate was 53 (83%) of 64 patients in the ublituximab plus ibrutinib group and 40 (65%) of 62 patients in the ibrutinib group (p=0·020). 117 patients, including 59 in the ublituximab plus ibrutinib group and 58 in the ibrutinib group, received at least one dose of treatment and were included in safety analyses. Most adverse events were grade 1 or 2. The most common grade 3 and 4 adverse events were neutropenia (11 [19%] patients in the ublituximab plus ibrutinib group and seven [12%] in the ibrutinib group), anaemia (five [8%] and five [9%]), and diarrhoea (six [10%] and three [5%]). The most common serious adverse events were pneumonia (six [10%] in the ublituximab plus ibrutinib group and four [7%] in the ibrutinib group), atrial fibrillation (four [7%] and one [2%]), sepsis (four [7%] and one [2%]), and febrile neutropenia (three [5%] and one [2%]). Two patients in the ublituximab plus ibrutinib group died due to adverse events (one cardiac arrest and one failure to thrive), neither of which were treatment-related. Five patients in the ibrutinib group died due to adverse events, including one cardiac arrest, one cerebral infarction, one intracranial haemorrhage, one Pneumocystis jirovecii pneumonia infection, and one unexplained death; the death due to cardiac arrest was considered to be treatment-related. INTERPRETATION The addition of ublituximab to ibrutinib resulted in a statistically higher overall response rate without affecting the safety profile of ibrutinib monotherapy in patients with relapsed or refractory high-risk chronic lymphocytic leukaemia. These findings provide support for the addition of ublituximab to Bruton tyrosine kinase inhibitors for the treatment of these patients. FUNDING TG Therapeutics.
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Affiliation(s)
- Jeff P Sharman
- Willamette Valley Cancer Institute, US Oncology Research, Eugene, OR, USA.
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Health System, Durham, NC, USA
| | - Anthony R Mato
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Suman Kambhampati
- Sarah Cannon Cancer Center at Research Medical Center, Kansas City, MO, USA
| | - John M Burke
- Rocky Mountain Cancer Centers, US Oncology Research, Aurora, CO, USA
| | - Frederick Lansigan
- Hematology/Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | - Alexander Zweibach
- Cancer Care Centers of South Texas, US Oncology Research, New Braunfels, TX, USA
| | | | | | | | | | | | | | | | - Ian W Flinn
- Sarah Cannon Research Institute, Nashville, TN, USA
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11
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Vanura K. Sex as decisive variable in lymphoid neoplasms-an update. ESMO Open 2020; 6:100001. [PMID: 33399069 PMCID: PMC7808098 DOI: 10.1016/j.esmoop.2020.100001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/09/2020] [Accepted: 10/31/2020] [Indexed: 01/26/2023] Open
Affiliation(s)
- K Vanura
- Department of Medicine I, Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria.
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12
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Lee CH, Chen PH, Lin C, Wang CY, Ho CL. A network meta-analysis of maintenance therapy in chronic lymphocytic leukemia. PLoS One 2020; 15:e0226879. [PMID: 31995577 PMCID: PMC6988939 DOI: 10.1371/journal.pone.0226879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 12/06/2019] [Indexed: 01/04/2023] Open
Abstract
Background Chronic lymphocytic leukemia (CLL) is incurable through conventional chemoimmunotherapy regimens. Despite durable responses to front-line therapy and sustained remission rates in patients with CLL, a majority of patients eventually relapse in 5 years of initial treatment. The depth of the response may affect the length of response. Maintenance therapies were aimed to deep remissions and extend the period of disease quiescence. Lenalidomide, rituximab and ofatumumab had demonstrated some efficacy as a maintenance therapy compared to no intervention for CLL patients. The relative effect on disease control and safety between different maintenance therapies were unclear. Methods We performed a systematic literature review and network meta-analysis to evaluate relative effect on disease control and safety of current available maintenance therapies. We searched PubMed, Embase and Cochrane database up to March 6, 2019. Relevant reference of review article and conference abstract including European Hematology Association Annual Meeting (EHA 2018), American Society of Hematology Annual Meeting (ASH 2018) and American Society of Clinical Oncology Annual Meeting (ASCO 2018) were searched. Randomized controlled trials (RCT) involving current available maintenance therapy including “Lenalidomide”, “Rituximab”, “Ofatumumab”, “Ibrutinib”, “Idelalisib”, “Venetoclax”and “Obinutuzumab”were eligible. Outcomes of interest included progression-free survival (PFS), overall survival (OS) and serious adverse events (SAE) in CLL patients received subsequent maintenance therapy. Two authors CHL and CL) independently assessed eligibility for all identified citations and extracted data from the original trial reports. The selected studies’ risk of bias was assessed following the guidelines of Cochrane Collaboration Handbook. Results In total, six phase III RCTs with total 1,615 CLL patients were identified. Maintenance therapy using lenalidomide, rituximab, and ofatumumab demonstrated a statistically significant effect in prolongation of progression-free survival (HR:0.37, 95% CI: 0.27–0.50 of lenalidomide; HR:0.50, 95% CI: 0.38–0.66 of rituximab; HR:0.52, 95% CI:0.41–0.66 of ofatumumab, separately) compared with no intervention; however, for overall survival, the effect of maintenance therapy showed no significant difference versus no intervention (HR: 0.89, 95% CI: 0.70–1.14). Lenalidomide showed the best efficacy for PFS (HR: 0.37, 95% CI: 0.27–0.50, Probability of being best treatment: 96%). Conclusions Our network meta-analysis provided an integrated overview of relative efficacy and safety of different maintenance therapies in CLL. All maintenance therapies were effective in reducing the risk of disease progression versus no intervention. Based on current best evidence, maintenance therapy with lenalidomide is the most efficacious option.
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Affiliation(s)
- Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Po-Huang Chen
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Research and Development, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chieh-Yung Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Ching-Liang Ho
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
- * E-mail:
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13
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van Oers M, Smolej L, Petrini M, Offner F, Grosicki S, Levin MD, Davis J, Banerjee H, Stefanelli T, Hoever P, Geisler C. Ofatumumab maintenance prolongs progression-free survival in relapsed chronic lymphocytic leukemia: final analysis of the PROLONG study. Blood Cancer J 2019; 9:98. [PMID: 31801940 PMCID: PMC6893027 DOI: 10.1038/s41408-019-0260-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/18/2019] [Accepted: 11/07/2019] [Indexed: 12/12/2022] Open
Abstract
We report the final analysis of the PROLONG study on ofatumumab maintenance in relapsed chronic lymphocytic leukemia (CLL). In all, 480 patients with CLL in complete or partial remission after second- or third-line treatment were randomized 1:1 to ofatumumab (300 mg first week, followed by 1000 mg every 8 weeks for up to 2 years) or observation. Median follow-up duration was 40.9 months. Median progression-free survival was 34.2 and 16.9 months for ofatumumab and observation arms, respectively, (hazard ratio, 0.55 [95% confidence interval, 0.43–0.70]; P < 0.0001). Median time to next treatment for ofatumumab and observation arms, respectively, was 37.4 and 27.6 months (0.72 [0.57–0.91]; P = 0.0044). Overall survival was similar in both arms; median was not reached (0.99 [0.72–1.37]). Grade ≥ 3 adverse events occurred in 62% and 51% of patients in ofatumumab and observation arms, respectively, the most common being neutropenia (23% and 10%), pneumonia (13% and 12%) and febrile neutropenia (6% and 4%). Up to 60 days after the last treatment, four deaths were reported in the ofatumumab arm versus six in the observation arm, none considered related to ofatumumab. Ofatumumab maintenance significantly prolonged progression-free survival in patients with relapsed CLL and was well tolerated.
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Affiliation(s)
- Marinus van Oers
- Academisch Medisch Centrum and HOVON, Amsterdam, The Netherlands.
| | - Lukas Smolej
- University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Mario Petrini
- Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Silesian Medical University, Katowice, Poland
| | - Mark-David Levin
- Albert Schweitzer Ziekenhuis Dordrecht and HOVON, Dordrecht, The Netherlands
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14
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Lee CH, Wu YY, Huang TC, Lin C, Zou YF, Cheng JC, Ho CL. Maintenance therapy for chronic lymphocytic leukaemia. Hippokratia 2019. [DOI: 10.1002/14651858.cd013474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Cho-Hao Lee
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Yi-Ying Wu
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Tzu-Chuan Huang
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
| | - Chin Lin
- National Defense Medical Center; School of Public Health; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Yi-Fen Zou
- Tri-Service General Hospital, National Defense Medical Center; Department of Pharmacy; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Ju-Chun Cheng
- Tri-Service General Hospital, National Defense Medical Center; Department of Pharmacy; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taipei Taiwan 114
| | - Ching-Liang Ho
- Tri-Service General Hospital, National Defense Medical Center; Division of Hematology and Oncology Medicine, Department of Internal Medicine; No.325, Sec. 2, Chenggong Rd.,Neihu Dist., Taipei City 114, Taiwan (R.O.C.) Taipei Taiwan Taiwan 114
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15
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García-Marco JA, Jiménez JL, Recasens V, Zarzoso MF, González-Barca E, De Marcos NS, Ramírez MJ, Parraga FJP, Yañez L, De La Serna Torroba J, Malo MDG, Ariznavarreta GD, Persona EP, Guinaldo MAR, De Paz Arias R, Llanos EB, Jarque I, Valle MDCF, Tatay AC, De Oteyza JP, Martin EMD, Fernández IP, Martinez RM, Costa MAA, Champ D, Suarez JG, Díaz MG, Ferrer S, Carbonell F, García-Vela JA. High prognostic value of measurable residual disease detection by flow cytometry in chronic lymphocytic leukemia patients treated with front-line fludarabine, cyclophosphamide, and rituximab, followed by three years of rituximab maintenance. Haematologica 2019; 104:2249-2257. [PMID: 30890600 PMCID: PMC6821631 DOI: 10.3324/haematol.2018.204891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 03/18/2019] [Indexed: 12/21/2022] Open
Abstract
It has been postulated that monitoring measurable residual disease (MRD) could be used as a surrogate marker of progression-free survival (PFS) in chronic lymphocytic leukemia (CLL) patients after treatment with immunochemotherapy regimens. In this study, we analyzed the outcome of 84 patients at 3 years of follow-up after first-line treatment with fludarabine, cyclophosphamide and rituximab (FCR) induction followed by 36 months of rituximab maintenance thearpy. MRD was assessed by a quantitative four-color flow cytometry panel with a sensitivity level of 10−4. Eighty out of 84 evaluable patients (95.2%) achieved at least a partial response or better at the end of induction. After clinical evaluation, 74 patients went into rituximab maintenance and the primary endpoint was assessed in the final analysis at 3 years of follow-up. Bone marrow (BM) MRD analysis was performed after the last planned induction course and every 6 months in cases with detectable residual disease during the 36 months of maintenance therapy. Thirty-seven patients (44%) did not have detectable residual disease in the BM prior to maintenance therapy. Interestingly, 29 patients with detectable residual disease in the BM after induction no longer had detectable disease in the BM following maintenance therapy. After a median followup of 6.30 years, the median overall survival (OS) and PFS had not been reached in patients with either undetectable or detectable residual disease in the BM, who had achieved a complete response at the time of starting maintenance therapy. Interestingly, univariate analysis showed that after rituximab maintenance OS was not affected by IGHV status (mutated vs. unmutated OS: 85.7% alive at 7.2 years vs. 79.6% alive at 7.3 years, respectively). As per protocol, 15 patients (17.8%), who achieved a complete response and undetectable peripheral blood and BM residual disease after four courses of induction, were allowed to stop fludarabine and cyclophosphamide and complete two additional courses of rituximab and continue with maintenance therapy for 18 cycles. Surprisingly, the outcome in this population was similar to that observed in patients who received the full six cycles of the induction regimen. These data show that, compared to historic controls, patients treated with FCR followed by rituximab maintenance have high-quality responses with fewer relapses and improved OS. The tolerability of this regime is favorable. Furthermore, attaining an early undetectable residual disease status could shorten the duration of chemoimmunotherapy, reducing toxicities and preventing long-term side effects. The analysis of BM MRD after fludarabine-based induction could be a powerful predictor of post-maintenance outcomes in patients with CLL undergoing rituximab maintenance and could be a valuable tool to identify patients at high risk of relapse, influencing further treatment strategies. This trial is registered with EudraCT n. 2007-002733-36 and ClinicalTrials.gov Identifier: NCT00545714.
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Affiliation(s)
| | | | | | | | - Eva González-Barca
- Hematology, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona
| | | | | | | | - Lucrecia Yañez
- Hospital Universitario Marqués de Valdecilla, Servicio de Hematologia, Santander
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marcos González Díaz
- Hematology, University Hospital of Salamanca-IBSAL, CIBERONC, USAL-CSIC, CIC-IBMCC, Salamanca
| | | | - Félix Carbonell
- Hematology, Consorcio Hospital General Universitario, Valencia
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16
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Egle A, Melchardt T, Obrtlíková P, Smolej L, Kozák T, Steurer M, Andel J, Burgstaller S, Mikušková E, Gercheva L, Nösslinger T, Papajík T, Ladická M, Girschikofsky M, Hrubiško M, Jäger U, Voskova D, Pecherstorfer M, Králiková E, Burcoveanu C, Spasov E, Petzer A, Mihaylov G, Raynov J, Oexle H, Zabernigg A, Flochová E, Palášthy S, Stehlíková O, Doubek M, Altenhofer P, Weiss L, Magnes T, Pleyer L, Klingler A, Mayer J, Greil R. Rituximab maintenance overcomes the negative prognostic factor of obesity in CLL: Subgroup analysis of the international randomized AGMT CLL-8a mabtenance trial. Cancer Med 2019; 8:1401-1405. [PMID: 30888118 PMCID: PMC6488104 DOI: 10.1002/cam4.1980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/18/2018] [Accepted: 12/27/2018] [Indexed: 11/29/2022] Open
Abstract
No data are available regarding obesity and outcome in Chronic Lymphocytic Leukemia (CLL). We analyzed 263 patients from the AGMT CLL‐8a Mabtenance trial for the impact of obesity. The trial included patients after rituximab‐containing induction treatment in first or second line that had achieved at least a PR. A randomization to rituximab maintenance treatment (375 mg/m2 q3 months for 2 years) vs observation was performed. In this cohort 22% of the patients (58/263) were classified as obese. The baseline response to induction treatment was inferior in obese patients with a lower CR rate (43.1% vs 60.5% in obese vs non‐obese, P = 0.018) and with a lower rate of patients achieving MRD negativity after chemoimmunotherapy induction treatment (19.6% vs 35.8%, P = 0.02). The PFS outcome of obese patients was significantly worse in the observation group of the trial (24 vs 39 months median PFS, P = 0.03). However, in the rituximab maintenance group the outcome for obese vs non‐obese was not different (P = 0.4). In summary, obesity was overall associated with a worse outcome of chemoimmunotherapy induction. However, rituximab maintenance treatment seems to be able to overcome this negative effect.
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Affiliation(s)
- Alexander Egle
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Thomas Melchardt
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Petra Obrtlíková
- First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Lukáš Smolej
- Fourth Department of Internal Medicine - Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Hradec Králové, Czech Republic
| | - Tomáš Kozák
- Department of Internal Medicine - Hematology, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michael Steurer
- Department of Internal Medicine V, Medical University Innsbruck, Innsbruck, Austria
| | | | - Sonja Burgstaller
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen GmbH, Wels, Austria
| | - Eva Mikušková
- Department of Hemato-oncology 2, National Cancer Institute Bratislava, Bratislava, Slovakia
| | - Liana Gercheva
- Clinic of Hematology, University Hospital St Marina Varna, Varna, Bulgaria
| | - Thomas Nösslinger
- Third Medical Department for Hematology and Oncology, Hanusch Krankenhaus der Wiener Gebietskrankenkasse, Vienna, Austria
| | - Tomáš Papajík
- Department of Hemato-oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Miriam Ladická
- Department of Clinical Oncology 1, National Cancer Institute Bratislava, Bratislava, Slovakia
| | | | - Mikuláš Hrubiško
- Clinic of Hematology and Transfusiology, Slovak Medical University, University Hospital Bratislava, Bratislava, Slovakia
| | - Ulrich Jäger
- Department of Medicine I, Division of Hematology and Hemostaeology, Medical University Vienna, Vienna, Austria
| | - Daniela Voskova
- Department of Internal Medicine 3, Kepler Universitätsklinikum GmbH, Med Campus III., Linz, Austria
| | - Martin Pecherstorfer
- Department of Internal Medicine 2, University Hospital Krems, Karl Landsteiner Private University of Health Sciences, Krems, Austria
| | - Eva Králiková
- Department of Hematology, FNsP F D Roosevelta Banská Bystrica, Banska Bystrica, Slovakia
| | | | - Emil Spasov
- Clinic of Hematology, UMHAT St George and Medical University Plovdiv, Plovdiv, Bulgaria
| | - Andreas Petzer
- Innere Medizin I, Ordensklinikum Linz GmbH, Linz, Austria
| | - Georgi Mihaylov
- Hematological Clinic NSHATHD Sofia, Queen Joanna University Hospital, Sofia, Bulgaria
| | - Julian Raynov
- Clinic of Medical Hematology, Military Medical Academy Sofia, Sofia, Bulgaria
| | - Horst Oexle
- Innere Medizin, Landeskrankenhaus Hall, Hall in Tirol, Austria
| | - August Zabernigg
- Innere Medizin II, Bezirkskrankenhaus Kufstein, Kufstein, Austria
| | - Emília Flochová
- Department of Hematology and Transfusion, University Hospital Martin, Martin, Slovakia
| | - Stanislav Palášthy
- Department of Clinical Hematology, FNsP, J A Reimana Prešov, Prešov, Slovakia
| | - Olga Stehlíková
- Faculty of Medicine and CEITEC, University Hospital Brno, Brno, Czech Republic
| | - Michael Doubek
- Faculty of Medicine and CEITEC, University Hospital Brno, Brno, Czech Republic
| | - Petra Altenhofer
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Lukas Weiss
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Teresa Magnes
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Lisa Pleyer
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
| | - Anton Klingler
- Assign Data Management and Biostatistics GmbH, Innsbruck, Austria
| | - Jiří Mayer
- Faculty of Medicine and CEITEC, University Hospital Brno, Brno, Czech Republic
| | - Richard Greil
- Third Medical Department, Paracelsus Medical University Salzburg, Salzburg, Austria.,Salzburg Cancer Research Institute (SCRI), Salzburg, Austria.,Cancer Cluster Salzburg (CCS), Salzburg, Austria
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17
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Herishanu Y, Tadmor T, Braester A, Bairey O, Aviv A, Rahimi‐Levene N, Fineman R, Levi I, Yuklea M, Ruchlemer R, Shvidel L, Polliack A. Low‐dose fludarabine and cyclophosphamide combined with standard dose rituximab (LD‐FCR) is an effective and safe regimen for elderly untreated patients with chronic lymphocytic leukemia: The Israeli CLL study group experience. Hematol Oncol 2019; 37:185-192. [DOI: 10.1002/hon.2580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/16/2019] [Accepted: 02/07/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Yair Herishanu
- Department of HematologyTel‐Aviv Sourasky Medical Center Tel‐Aviv Israel
- Sackler Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
| | - Tamar Tadmor
- Hematology UnitBnai‐Zion Medical Center Haifa Israel
| | - Andrei Braester
- Department of HematologyGalilee Medical Center and Faculty of Medicine in Galilee Nahariya Israel
| | - Osnat Bairey
- Sackler Faculty of MedicineTel‐Aviv University Tel‐Aviv Israel
- Department of HematologyRabin Medical Center Petah Tikva Israel
| | - Ariel Aviv
- Department of HematologyEmek Medical Center Afula Israel
| | | | - Riva Fineman
- Department of HematologyRambam Medical Center Haifa Israel
| | - Itai Levi
- Department of HematologySoroka Medical Center, Beer Sheba and Ben‐Gurion University, Beer Sheba Israel
| | - Mona Yuklea
- Department of HematologySapir Medical Center Kfar Saba Israel
| | - Rosa Ruchlemer
- Department of HematologyShaare Zedek Medical Center Jerusalem Israel
| | - Lev Shvidel
- Department of HematologyKaplan Medical Center Rehovot Israel
| | - Aaron Polliack
- Department of HematologyHadassah University Hospital and Hebrew University Medical School Jerusalem Israel
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18
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Owen C, Gerrie AS, Banerji V, Assouline S, Chen C, Robinson KS, Lye E, Fraser G. Canadian evidence-based guideline for the first-line treatment of chronic lymphocytic leukemia. Curr Oncol 2018; 25:e461-e474. [PMID: 30464698 PMCID: PMC6209557 DOI: 10.3747/co.25.4092] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In Canada, no unified national guideline exists for the front-line treatment of cll; provincial guidelines vary and are largely based on funding. A group of clinical experts from across Canada developed a national evidence-based treatment guideline to provide health care professionals with clear guidance on the first-line management of cll. Consensus recommendations based on available evidence are presented for the first-line treatment of cll.
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Affiliation(s)
- C Owen
- Division of Hematology and Hematological Malignancies, Foothills Medical Centre, Calgary, AB
| | - A S Gerrie
- Division of Medical Oncology, University of British Columbia and BC Cancer, Vancouver, BC
| | - V Banerji
- Department of Hematology and Medical Oncology, Cancer Care Manitoba, Winnipeg, MB
| | - S Assouline
- Department of Medical Oncology, McGill University and Jewish General Hospital, Montreal, QC
| | - C Chen
- Department of Medical Oncology, University of Toronto, and Princess Margaret Cancer Centre, Toronto, ON
| | - K S Robinson
- Division of Hematology, Dalhousie University, and qeii Health Sciences Centre, Halifax, NS
| | - E Lye
- Lymphoma Canada, Mississauga, ON
| | - G Fraser
- Department of Oncology, McMaster University, and Juravinski Cancer Centre, Hamilton, ON
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19
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Egle A, Pleyer L, Melchardt T, Hartmann TN, Greil R. Remission maintenance treatment options in chronic lymphocytic leukemia. Cancer Treat Rev 2018; 70:56-66. [PMID: 30121491 DOI: 10.1016/j.ctrv.2018.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/02/2018] [Accepted: 08/07/2018] [Indexed: 02/07/2023]
Abstract
Chronic lymphocytic leukemia (CLL) treatment has come a long way in the last two decades, producing increases in tumor control to the point of generating sizeable numbers of patients with undetectable minimal residual disease and creating overall survival benefits in randomized comparisons. Most of this has been achieved by limited-term treatment approaches including chemotherapeutic and immune-therapeutic drugs. More recently, novel therapies targeting signaling pathways essential for the survival of the neoplastic clones have opened avenues that provide disease control in long-term treatment designs, mostly without producing deep remissions. In this disease, where current treatments are largely unable to effect a cure, prolonged therapy designs using maintenance approaches are explored and 5 randomized studies of maintenance have recently been published. This review shall summarize available results from a systematic literature review in a clinical context and outline basic biology principles that should be heeded in this regard.
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Affiliation(s)
- Alexander Egle
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Lisa Pleyer
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Thomas Melchardt
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Tanja Nicole Hartmann
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria
| | - Richard Greil
- Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Disease, Rheumatology, Oncologic Center, Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute and Cancer Cluster Salzburg, Austria.
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20
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Methods and role of minimal residual disease after stem cell transplantation. Bone Marrow Transplant 2018; 54:681-690. [PMID: 30116018 DOI: 10.1038/s41409-018-0307-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/28/2018] [Accepted: 06/13/2018] [Indexed: 11/08/2022]
Abstract
Relapse is the major cause of treatment failure after stem cell transplantation. Despite the fact that relapses occurred even if transplantation was performed in complete remission, it is obvious that minimal residual disease is present though not morphologically evident. Since adaptive immunotherapy by donor lymphocyte infusion or other novel cell therapies as well as less toxic drugs, which can be used after transplantation, the detection of minimal residual disease (MRD) has become a clinical important variable for outcome. Besides the increasing options to treat MRD, the most advanced technologies currently allow to detect residual malignant cells with a sensitivity of 10-5 to 10-6.Under the patronage of the European Society for Blood and Marrow Transplantation (EBMT) and the American Society for Blood and Marrow Transplantation (ASBMT) the 3rd workshop was held on 4/5 November 2016 in Hamburg/Germany, with the aim to present an up-to-date status of epidemiology and biology of relapse and to summarize the currently available options to prevent and treat post-transplant relapse. Here the current methods and role of minimal residual disease for myeloid and lymphoid malignancies are summarized.
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21
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Yang Y, Qiu J, Snyder-Keller A, Wu Y, Sun S, Sui H, Dean AB, Kramer L, Hernandez-Ilizaliturri F. Fatal Cache Valley virus meningoencephalitis associated with rituximab maintenance therapy. Am J Hematol 2018; 93:590-594. [PMID: 29282755 DOI: 10.1002/ajh.25024] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 12/20/2017] [Accepted: 12/26/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Yuanquan Yang
- Department of Medicine; Roswell Park Cancer Institute; Buffalo New York
| | - Jingxin Qiu
- Department of Pathology; Roswell Park Cancer Institute; Buffalo New York
| | | | - Yongping Wu
- Wadsworth Center, New York State Department of Health; Albany New York
| | - Shufeng Sun
- Wadsworth Center, New York State Department of Health; Albany New York
| | - Haixin Sui
- Wadsworth Center, New York State Department of Health; Albany New York
| | - Amy B. Dean
- Wadsworth Center, New York State Department of Health; Albany New York
| | - Laura Kramer
- Wadsworth Center, New York State Department of Health; Albany New York
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22
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Schuh AH, Parry-Jones N, Appleby N, Bloor A, Dearden CE, Fegan C, Follows G, Fox CP, Iyengar S, Kennedy B, McCarthy H, Parry HM, Patten P, Pettitt AR, Ringshausen I, Walewska R, Hillmen P. Guideline for the treatment of chronic lymphocytic leukaemia: A British Society for Haematology Guideline. Br J Haematol 2018; 182:344-359. [PMID: 30009455 DOI: 10.1111/bjh.15460] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna H Schuh
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Abergavenny, UK
| | - Niamh Appleby
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | | | | | | | - Christopher P Fox
- Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ben Kennedy
- Department of Haematology, University Hospital Leicester, Leicester, UK
| | - Helen McCarthy
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Helen M Parry
- NIHR-ACL Haematology, University of Birmingham, Birmingham, UK
| | | | | | | | - Renata Walewska
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Peter Hillmen
- Haematology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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23
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Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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24
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Strati P, Jain N, O'Brien S. Chronic Lymphocytic Leukemia: Diagnosis and Treatment. Mayo Clin Proc 2018; 93:651-664. [PMID: 29728204 DOI: 10.1016/j.mayocp.2018.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/30/2018] [Accepted: 03/02/2018] [Indexed: 12/27/2022]
Abstract
The complexity of the treatment of patients with chronic lymphocytic leukemia has increased substantially over the past several years as a consequence of the advent of novel biological agents such as ibrutinib, idelalisib, and venetoclax, as well as increasingly potent anti-CD20 monoclonal antibodies. In addition, the identification of molecular predictive markers and the introduction of more sensitive and sophisticated techniques to assess minimal residual disease have allowed optimization of the use of chemoimmunotherapy and targeted therapies and may become standard of care in the future. This review summarizes the diagnosis, prognostication, and treatment of patients with chronic lymphocytic leukemia with emphasis on new prognostic and predictive factors and novel treatment strategies.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
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Affiliation(s)
- Paolo Strati
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA.
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25
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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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26
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Robak T, Błoński J, Skotnicki AB, Piotrowska M, Wróbel T, Rybka J, Kłoczko J, Bołkun Ł, Budziszewska BK, Walczak U, Uss A, Fidecka M, Smolewski P. Rituximab, cladribine, and cyclophosphamide (RCC) induction with rituximab maintenance in chronic lymphocytic leukemia: PALG - CLL4 (ML21283) trial. Eur J Haematol 2018; 100:465-474. [PMID: 29427355 DOI: 10.1111/ejh.13042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES PALG CLL4 is the first, randomized, phase IIIb study with rituximab, cladribine, and cyclophosphamide (RCC) induction and subsequent maintenance with rituximab in previously untreated chronic lymphocytic leukemia (CLL) patients. METHODS The induction treatment consisted of 6 RCC cycles regimen. Patients with complete response (CR) or partial response (PR) after an induction phase were randomized into a maintenance arm with rituximab or an observational arm. RESULTS In the intention-to-treat population, 97 patients completed the induction phase with an overall response rate (ORR) of 73.2% (CR 22.7%, PR 50.5%). Subsequently, 66 patients were randomized into the rituximab maintenance arm (n = 33) or the observational arm (n = 33). CR rates were 57.1% in the maintenance group vs 50% in the observational group. PFS was significantly longer in the rituximab maintenance vs the observational arm (P = .028). The multivariate Cox model indicated that del17p (P = .006) and elevated beta-2-microglobulin (P = .015) significantly increased the hazard ratio (HR) of progression, whereas the presence of CD38 (P = .013) significantly decreased it; maintenance therapy with rituximab (P < .0001) significantly decreased the HR of disease progression. CONCLUSIONS The study confirmed the high efficacy and acceptable safety profile of induction therapy with RCC and maintenance therapy with rituximab in previously untreated patients with CLL.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | - Jerzy Błoński
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | | | | | - Tomasz Wróbel
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Justyna Rybka
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Janusz Kłoczko
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | - Łukasz Bołkun
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | | | - Urszula Walczak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Anatoly Uss
- City Clinical Hospital No. 9, Minsk, Belarus
| | | | - Piotr Smolewski
- Department of Experimental Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
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28
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Influence of FCGR3A-158V/F Genotype and Baseline CD20 Antigen Count on Target-Mediated Elimination of Rituximab in Patients with Chronic Lymphocytic Leukemia: A Study of FILO Group. Clin Pharmacokinet 2018; 56:635-647. [PMID: 27783363 DOI: 10.1007/s40262-016-0470-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Rituximab is an anti-CD20 monoclonal antibody approved in the first-line treatment of patients with chronic lymphocytic leukemia (CLL). Rituximab pharmacokinetics shows a time dependency possibly related to changes in the target antigen amount over time. The purpose of this study was to quantify the influence of both CD20 antigenic mass and the FcγRIIIA genetic polymorphism on rituximab pharmacokinetics in CLL. METHODS Rituximab pharmacokinetics was described in 118 CLL patients using a semi-mechanistic model including a latent target antigen turnover, which allowed the estimation of rituximab target-mediated elimination in addition to the endogenous clearance. RESULTS Target-mediated elimination rate constant increased with the baseline CD20 count on circulating B cells (p = 0.00046) and in patients with the FCGR3A-158VV genotype (p = 0.0016). Physiologic elimination of antigen was lower in the Binet C disease stage (p = 0.00018). The effects of these covariates on rituximab concentrations were mainly visible at the beginning of treatment. Body surface area also increased central and peripheral volumes of distribution (p = 1.3 × 10-5 and 0.0015, respectively). CONCLUSIONS A pharmacokinetic model including target-mediated elimination accurately described rituximab concentrations in CLL and showed that rituximab 'consumption' (target-mediated elimination) increases with increasing baseline antigen count on circulating B cells and in FCGR3A-158VV patients. CLINICAL TRIAL REGISTRATION NCT01370772.
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29
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Dartigeas C, Van Den Neste E, Léger J, Maisonneuve H, Berthou C, Dilhuydy MS, De Guibert S, Leprêtre S, Béné MC, Nguyen-Khac F, Letestu R, Cymbalista F, Rodon P, Aurran-Schleinitz T, Vilque JP, Tournilhac O, Mahé B, Laribi K, Michallet AS, Delmer A, Feugier P, Lévy V, Delépine R, Colombat P, Leblond V. Rituximab maintenance versus observation following abbreviated induction with chemoimmunotherapy in elderly patients with previously untreated chronic lymphocytic leukaemia (CLL 2007 SA): an open-label, randomised phase 3 study. LANCET HAEMATOLOGY 2017; 5:e82-e94. [PMID: 29275118 DOI: 10.1016/s2352-3026(17)30235-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Most patients with chronic lymphocytic leukaemia relapse after initial therapy combining chemotherapy with rituximab. We assessed the efficacy and safety of rituximab maintenance treatment versus observation for elderly patients in remission after front-line abbreviated induction by fludarabine, cyclophosphamide, and rituximab (FCR). METHODS This randomised, open-label, multicentre phase 3 trial at 89 centres in France enrolled treatment-naive and fit patients aged 65 years or older with chronic lymphocytic leukaemia without del(17p). Eligible patients had an Eastern Cooperative Oncology Group performance status of 0-1 and adequate renal and hepatic function. Patients in response to complete induction treatment with four monthly courses of full-dose FCR with two interim rituximab doses on day 14 of cycles 1 and 2 (oral fludarabine [40 mg/m2 per day] and oral cyclophosphamide [250 mg/m2 per day] for the first 3 days of each cycle, rituximab at 375 mg/m2 intravenously on day 0 of cycle 1 and subsequently at 500 mg/m2 on day 14 of cycle 1, days 1 and 14 of cycle 2, and day 1 of cycles 3 and 4) were eligible for randomisation. Recovery from FCR toxicity and patient willingness to continue the trial were mandatory. We randomly assigned (1:1) patients to either receive intravenous rituximab (500 mg/m2) every 8 weeks for up to 2 years or undergo observation, with a central computer-generated randomisation list using randomly permuted blocks of variable sizes. Randomisation was stratified by IGHV mutational status, the presence or absence of del(11q), and response level to induction treatment. The primary endpoint was progression-free survival, with the objective to assess the superiority of rituximab maintenance relative to observation. The final analysis was done in the intention-to-treat population. Safety was analysed in all patients who received at least one dose of study drug in the rituximab group and in all patients in the observation group. This trial is closed to accrual whilst continuing patient follow-up. The study is registered with ClinicalTrials.gov, number NCT00645606. FINDINGS Between Dec 14, 2007, and Feb 18, 2014, 542 patients were enrolled, of whom 525 started FCR induction. Between June 10, 2008, and Aug 14, 2014, 409 (78%) patients were randomly assigned to rituximab maintenance (n=202) or observation (n=207). Four (2%) patients in the rituximab group did not receive the allocated treatment (progressive disease [n=1], adverse events [n=3]). After a median follow-up of 47·7 months (IQR 30·4-65·8), median progression-free survival in the rituximab group (59·3 months, 95% CI 49·6-not estimable) was improved compared with the observation group (49·0 months, 39·9-60·5; hazard ratio 0·55, 95% CI 0·40-0·75; p=0·0002). Neutropenia and grade 3-4 infections were more common with rituximab maintenance (105 [53%] of 198 patients vs 74 [36%] of 207 patients and 38 [19%] vs 21 [10%], respectively) during the study. The most common grade 3-4 infection was lower respiratory tract infection (24 [12%] vs eight [4%]). The incidence of second cancers, except basal cell carcinoma, was similar in both groups (29 [15%] vs 23 [11%]). Deaths were related to adverse events for 23 (11%) patients in the rituximab group and 16 (8%) in the observation group. INTERPRETATION 2-year maintenance rituximab in selected elderly patients improves progression-free survival and shows an acceptable safety profile. Immunotherapy maintenance strategy is a relevant option in front-line treatment of chronic lymphocytic leukaemia, even in the age of targeted therapy. FUNDING French National Cancer Institute (INCa), Roche, Chugai.
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Affiliation(s)
- Caroline Dartigeas
- Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Tours, France.
| | - Eric Van Den Neste
- Cancérologie et Hématologie, Cliniques Universitaires UCL Saint-Luc, Brussels, Belgium
| | | | - Hervé Maisonneuve
- Médecine Interne Onco-Hématologie, Centre Hospitalier Départemental de Vendée, La Roche Sur Yon, France
| | | | - Marie-Sarah Dilhuydy
- Hématologie Clinique et Thérapie Cellulaire, Hôpital Haut Lévêque, CHU Bordeaux, Pessac, France
| | - Sophie De Guibert
- Hématologie Clinique, Hôpital Pontchaillou, CHU Rennes, Rennes, France
| | - Stéphane Leprêtre
- Département d'Hématologie, Centre Henri Becquerel, Inserm U1245, Université de Normandie, Rouen, France
| | - Marie C Béné
- Service d'Hématologie Biologique, CHU Nantes, Nantes, France
| | - Florence Nguyen-Khac
- Unité de Cytogénétique Hématologique, Hôpital Pitié-Salpêtrière, AP-HP, Inserm U1138, Université Paris 6, Paris, France
| | - Rémi Letestu
- Service d'Hématologie Biologique, Hôpital Avicenne, AP-HP, Bobigny, France
| | | | - Philippe Rodon
- Onco-Hématologie, Centre Hospitalier de Blois, Blois, France
| | | | - Jean-Pierre Vilque
- Institut d'Hématologie, Hôpital François Baclesse, CHU Caen, Caen, France
| | - Olivier Tournilhac
- Hématologie Clinique et Thérapie Cellulaire, Hôpital d'Estaing, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Béatrice Mahé
- Hématologie Clinique, Hôpital Hôtel Dieu, CHU Nantes, Nantes, France
| | - Kamel Laribi
- Hématologie, Centre Hospitalier du Mans, Le Mans, France
| | - Anne-Sophie Michallet
- Hématologie Clinique, Hospices Civils de Lyon, CHU Lyon, Hématologie, Centre Léon Bérard, Lyon, France
| | - Alain Delmer
- Hématologie Clinique, Hôpital Robert Debré, CHU Reims, Université de Reims Champagne-Ardenne, Reims, France
| | - Pierre Feugier
- Hématologie, Hôpitaux de Brabois, CHU Nancy, Inserm U954, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Vincent Lévy
- URC/CRC, Groupe Hospitalier Paris Seine Saint Denis, AP-HP, Inserm U1153, Université Paris 13, Bobigny, France
| | - Roselyne Delépine
- French Innovative Leukemia Organization FILO, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Philippe Colombat
- Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHU Tours, Tours, France
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Chanan-Khan AA, Zaritskey A, Egyed M, Vokurka S, Semochkin S, Schuh A, Kassis J, Simpson D, Zhang J, Purse B, Foà R. Lenalidomide maintenance therapy in previously treated chronic lymphocytic leukaemia (CONTINUUM): a randomised, double-blind, placebo-controlled, phase 3 trial. LANCET HAEMATOLOGY 2017; 4:e534-e543. [PMID: 28958469 DOI: 10.1016/s2352-3026(17)30168-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/09/2017] [Accepted: 08/11/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The efficacy and safety of lenalidomide as maintenance therapy after chemotherapy-based second-line therapy in patients with chronic lymphocytic leukaemia is unknown. Although kinase inhibitors can improve outcomes for some patients with relapsed and refractory disease, not all patients have access to these novel drugs. In this study, we aimed to assess the efficacy and safety of lenalidomide as maintenance therapy in patients with previously treated chronic lymphocytic leukaemia. METHODS This randomised, double-blind, placebo-controlled, phase 3 trial (CONTINUUM) was done at 111 hospitals, medical centres, and clinics in 21 countries. Patients were eligible if they had chronic lymphocytic leukaemia; were aged 18 years or older; had been treated with two lines of therapy (with at least a partial response after second-line therapy); had received a purine analogue, bendamustine, anti-CD20 antibody, chlorambucil, or alemtuzumab as first-line or second-line treatment; and had an Eastern Cooperative Oncology Group performance score of 0-2. Eligible patients were randomly assigned (1:1) by an interactive voice-response system to receive either oral lenalidomide (2·5 mg/day) or matching oral placebo capsules (2·5 mg/day) for 28-day cycles, until disease progression or unacceptable toxicity. Lenalidomide dose escalation (to 5 mg or 10 mg per day) was permitted if the drug was well tolerated. Patients, investigators, and those completing data analyses were masked to treatment allocation. Randomisation was stratified by age, response to second-line therapy, and prognostic factors. Co-primary endpoints were progression-free survival and overall survival; the primary endpoint was later changed to overall survival after the data cutoff for this analysis. Secondary endpoints were time from randomisation to second disease progression or death (PFS2),32 tumour response (improvement in response and duration of response), safety, and health-related quality of life (HRQoL). Efficacy analyses were done in the intention-to-treat population. Safety was analysed in all patients who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov, number NCT00774345, and is closed to accrual, but follow-up is ongoing. FINDINGS Between Feb 16, 2009 and Sept 29, 2015, 314 patients with chronic lymphocytic leukaemia were enrolled and randomly assigned to receive either lenalidomide (n=160) or placebo (n=154). With a median follow-up of 31·5 months (IQR 18·9-50·8), there was no significant difference in overall survival between the lenalidomide and the placebo groups (median 70·4 months, 95% CI 57·5-not estimable [NE] vs NE, 95% CI 62·8-NE; hazard ratio [HR] 0·96, 95% CI 0·63-1·48; p=0·86). Progression-free survival was significantly longer in the lenalidomide group (median 33·9 months, 95% CI 25·5-52·5) than in the placebo group (9·2 months, 7·4-13·6; HR 0·40, 95% CI 0·29-0·55; p<0·0001). PFS2 was significantly longer in the lenalidomide group than in the placebo group (median 57·5 months [47·7-NE] vs 32·7 months [26·4-49·0]; HR 0·46, 95% CI 0·29-0·70; p<0·01). Improved responses from baseline were observed in ten (6%) of 160 lenalidomide-treated patients versus four (3%) of 154 placebo-treated patients (p=0·12). Median time to improved response was 12·2 weeks (IQR 7·2-22·5) in the lenalidomide group versus 76·3 weeks (20·2-182·6) in the placebo group. Duration of improved response was not estimable in either group (95% CI 22·9-NE in the lenalidomide group vs NE-NE for placebo). There were no clinically meaningful differences in HRQoL between lenalidomide-treated patients and placebo-treated patients, as measured by FACT-Leu and EQ-5D, during maintenance treatment. In the safety population, the most common grade 3 or 4 adverse events included neutropenia (94 [60%] of 157 patients in the lenalidomide group vs 35 [23%] of 154 patients in the placebo group), thrombocytopenia (26 [17%] vs ten [6%]), and diarrhoea (13 [8%] vs one [<1%]). There were five fatal adverse events (three [2%] patients in the lenalidomide group and two [1%] patients in the placebo group). INTERPRETATION Lenalidomide might delay time to subsequent therapy and does not adversely affect response to subsequent therapy. Chemoimmunotherapy followed by lenalidomide maintenance could be an effective treatment option for patients with chronic lymphocytic leukaemia who do not have access to kinase inhibitors. FUNDING Celgene Corporation.
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Affiliation(s)
| | - Andrey Zaritskey
- Institute of Hematology, Federal Almazov North-West Medical Research Centre, St Petersburg, Russia
| | - Miklos Egyed
- Department of Internal Medicine, Kaposi Mór Teaching Hospital, Kaspovár, Hungary
| | - Samuel Vokurka
- Department of Haemato-oncology, University Hospital Pilsen, Plzeň, Czech Republic
| | - Sergey Semochkin
- Division of Oncology and Hematology, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Anna Schuh
- Department of Oncology, University of Oxford, Oxford, UK
| | - Jeannine Kassis
- Department of Hematology, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - David Simpson
- Department of Haematology, North Shore Hospital, Auckland, New Zealand
| | | | | | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, Sapienza University, Rome, Italy
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Lenalidomide maintenance in high risk chronic lymphocytic leukaemia: practice changing study or hypothesis generating approach? LANCET HAEMATOLOGY 2017; 4:e455-e456. [PMID: 28916312 DOI: 10.1016/s2352-3026(17)30178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/24/2022]
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Fink AM, Bahlo J, Robrecht S, Al-Sawaf O, Aldaoud A, Hebart H, Jentsch-Ullrich K, Dörfel S, Fischer K, Wendtner CM, Nösslinger T, Ghia P, Bosch F, Kater AP, Döhner H, Kneba M, Kreuzer KA, Tausch E, Stilgenbauer S, Ritgen M, Böttcher S, Eichhorst B, Hallek M. Lenalidomide maintenance after first-line therapy for high-risk chronic lymphocytic leukaemia (CLLM1): final results from a randomised, double-blind, phase 3 study. LANCET HAEMATOLOGY 2017; 4:e475-e486. [PMID: 28916311 DOI: 10.1016/s2352-3026(17)30171-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/03/2017] [Accepted: 08/04/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND The combined use of genetic markers and detectable minimal residual disease identifies patients with chronic lymphocytic leukaemia with poor outcome after first-line chemoimmunotherapy. We aimed to assess lenalidomide maintenance therapy in these high-risk patients. METHODS In this randomised, double-blind, phase 3 study (CLLM1; CLL Maintenance 1 of the German CLL Study Group), patients older than 18 years and diagnosed with immunophenotypically confirmed chronic lymphocytic leukaemia with active disease, who responded to chemoimmunotherapy 2-5 months after completion of first-line therapy and who were assessed as having a high risk for an early progression with at least a partial response after four or more cycles of first-line chemoimmunotherapy, were eligible if they had high minimal residual disease levels or intermediate levels combined with an unmutated IGHV gene status or TP53 alterations. Patients were randomly assigned (2:1) to receive either lenalidomide (5 mg) or placebo. Randomisation was done with a fixed block size of three, and was stratified according to the minimal residual disease level achieved after first-line therapy. Maintenance was started with 5 mg daily, and was escalated to the target dose of 15 mg. If tolerated, medication was administered until disease progression. The primary endpoint was progression-free survival according to an independent review. The pre-planned interim analysis done by intention to treat was done after 20% of the calculated progression-free survival events. This study is registered with ClinicalTrials.gov, number NCT01556776; treatment in the lenalidomide group is still ongoing. FINDINGS Between July 5, 2012, and March 15, 2016, 468 previously untreated patients with chronic lymphocytic leukaemia were screened for the study; 379 (81%) were not eligible. Recruitment was closed prematurely due to poor accrual after 89 of 200 planned patients were randomly assigned: 60 (67%) enrolled patients were assigned to the lenalidomide group and 29 (33%) to the placebo group, of whom 56 (63%) received lenalidomide and 29 (33%) placebo, with a median of 11·0 (IQR 4·5-20·5) treatment cycles at data cutoff. After a median observation time of 17·9 months (IQR 9·1-28·1), the hazard ratio for progression-free survival assessed by an independent review was 0·168 (95% CI 0·074-0·379). Median progression-free survival was 13·3 months (95% CI 9·9-19·7) in the placebo group and not reached (95% CI 32·3-not evaluable) in the lenalidomide group. The most frequent adverse events were skin disorders (35 patients [63%] in the lenalidomide group vs eight patients [28%] in the placebo group), gastrointestinal disorders (34 [61%] vs eight [28%]), infections (30 [54%] vs 19 [66%]), haematological toxicity (28 [50%] vs five [17%]), and general disorders (28 [50%] vs nine [31%]). One fatal adverse event was reported in each of the treatment groups (one [2%] patient with fatal acute lymphocytic leukaemia in the lenalidomide group and one patient (3%) with fatal multifocal leukoencephalopathy in the placebo group). INTERPRETATION Lenalidomide is an efficacious maintenance therapy reducing the relative risk of progression in first-line patients with chronic lymphocytic leukaemia who do not achieve minimal residual disease negative disease state following chemoimmunotherapy approaches. The toxicity seems to be acceptable considering the poor prognosis of the eligible patients. The trial independently confirms the clinical significance of a novel, minimal residual disease-based algorithm to predict short progression-free survival, which might be incorporated in future clinical trials to identify candidates for additional maintenance treatment. FUNDING Celgene Corporation.
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Affiliation(s)
- Anna Maria Fink
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany.
| | - Jasmin Bahlo
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Ali Aldaoud
- Gemeinschaftspraxis für Hämatologie und Onkologie, Leipzig, Germany
| | - Holger Hebart
- Zentrum für Innere Medizin, Hämatologie/Onkologie, Stauferklinikum Schwäbisch-Gmünd, Germany
| | | | | | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Clemens-Martin Wendtner
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany; Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, Klinikum Schwabing, Munich, Germany
| | - Thomas Nösslinger
- 3rd Department for Hematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Paolo Ghia
- Strategic Research Program on CLL, Università Vita-Salute San Raffaele and IRCCS Istituto Scientifico San Raffaele, Milan, Italy
| | - Francesc Bosch
- Department of Hematology, University Hospital Vall d'Hebron, Barcelona, Spain; on behalf of the Spanish Group of CLL (GELLC)
| | - Arnon P Kater
- Department of Hematology, Academic Medical Center Amsterdam, University of Amsterdam, Netherlands; on behalf of the Dutch-Belgium HOVON CLL study group
| | - Hartmut Döhner
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Michael Kneba
- Campus Kiel, 2nd Deptartment of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Eugen Tausch
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | | | - Matthias Ritgen
- Campus Kiel, 2nd Deptartment of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Sebastian Böttcher
- Campus Kiel, 2nd Deptartment of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany; Department of Medicine III-Hematology/Oncology/Palliative Care, Rostock University Medical Center, Rostock, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study Group, University Hospital of Cologne, Cologne, Germany
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Maintenance Therapies in Indolent Lymphomas: should Recent Data Change the Standard of Care? Curr Treat Options Oncol 2017; 18:16. [PMID: 28286923 DOI: 10.1007/s11864-017-0459-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OPINION STATEMENT The overall benefit of maintenance therapy for patients with an indolent lymphoma continues to go unanswered. A myriad of variables contribute to the lack of clear clinical guidance. First, the disease course is slow and treatment may not be required for years, requiring a long follow-up to prospectively study. Second, due to the long lag time from study initiation to conclusion, many of the induction therapies used at the onset of the study may not be favored at present, providing a conclusion that cannot be reconciled with current clinical practice. For example, bendamustine and rituximab are typically the favored initial treatment agents in follicular lymphoma, which was not true when many maintenance trials were initiated. Third, several studies' inclusion criteria allow for patient enrollment at both initial diagnosis as well as at disease recurrence. In some studies, patients who are asymptomatic are started on therapy, counter to the accepted watch and wait approach. This contributes to the difficulty of generalizing results. The question of the benefit of maintenance therapy has been studied enough, and there may not be a smoking gun in the foreseeable future. However, what does hold promise is focusing on the patients with minimum residual disease after conclusion of chemotherapy. This may be a population that could receive benefit from a prolonged treatment approach. In the meantime, maintenance therapy should not be used in all patients, and the rationale for use should be data-driven, as well as an assessment of a patient's potential intolerability of cytotoxic chemotherapy.
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Concordant bone marrow involvement of diffuse large B-cell lymphoma represents a distinct clinical and biological entity in the era of immunotherapy. Leukemia 2017; 32:353-363. [PMID: 28745330 DOI: 10.1038/leu.2017.222] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/24/2017] [Accepted: 06/29/2017] [Indexed: 12/24/2022]
Abstract
In diffuse large B-cell lymphoma (DLBCL), the clinical and biological significance of concordant and discordant bone marrow (BM) involvement have not been well investigated. We evaluated 712 de novo DLBCL patients with front-line rituximab-containing treatment, including 263 patients with positive and 449 with negative BM status. Compared with negative BM disease, concordant BM adversely impacted overall and progression-free survival, independent of the International Prognostic Index (IPI) and cell-of-origin classification. Once BM is concordantly involved, poor prognosis was not associated with the extent of BM involvement. Conversely, patients with discordant BM showed favorable overall survival similar to stage I-II DLBCL. A BM-adjusted IPI, using three parameters: concordant BM involvement, age >60 years, and performance status >1, improves the risk stratification for DLBCL with positive BM. Intensive immunochemotherapy seemingly rendered survival benefit for patients with concordant BM, as did rituximab maintenance for the discordant BM group. Frequently revealing adverse clinical and molecular characteristics, patients with concordant BM demonstrated gene expression signatures relevant to tumor cell proliferation, migration and immune escape. In conclusion, clinical and biological heterogeneity is seen in DLBCL with positive BM but concordant BM involvement represents a distinct subset with unfavorable gene signatures, high-risk clinicopathologic features and poor prognosis.
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Butler LA, Tam CS, Seymour JF. Dancing partners at the ball: Rational selection of next generation anti-CD20 antibodies for combination therapy of chronic lymphocytic leukemia in the novel agents era. Blood Rev 2017; 31:318-327. [PMID: 28499646 DOI: 10.1016/j.blre.2017.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023]
Abstract
The anti-CD20 antibodies represent a major advancement in the therapeutic options available for chronic lymphocytic leukemia. The addition of rituximab, ofatumumab and obinutuzumab to various chemotherapy regimens has led to considerable improvements in both response and survival. Ocaratuzumab, veltuzumab and ublituximab are currently being explored within the trial setting. We review the current status of these antibodies, and discuss how their mechanisms of action may impact on the choice of combinations with novel small molecule agents.
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Affiliation(s)
- L A Butler
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - C S Tam
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia
| | - J F Seymour
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia.
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Egle A. Milestones in Chronic Lymphocytic Leukemia: An exciting decade of progress-10th anniversary of memo. MEMO 2017; 10:8-12. [PMID: 28367250 PMCID: PMC5357250 DOI: 10.1007/s12254-017-0318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/03/2017] [Indexed: 06/07/2023]
Abstract
The past 10 years have been an exciting ride for Chronic Lymphocytic Leukemia (CLL) aficionados. An overview of changes in management paradigms in CLL, ranging from insights into biology, via chemotherapy and chemoimmunotherapy to maintenance and novel drugs will be presented.
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Affiliation(s)
- Alexander Egle
- 3rd Medical Department, Paracelsus Private Medical University Hospital Salzburg, Muellnerhauptstrasse 48, 5020 Salzburg, Austria
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Pavanello F, Zucca E, Ghielmini M. Rituximab: 13 open questions after 20years of clinical use. Cancer Treat Rev 2017; 53:38-46. [DOI: 10.1016/j.ctrv.2016.11.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/20/2016] [Accepted: 11/29/2016] [Indexed: 12/26/2022]
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Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG, O'Brien S, Gribben J, Rai K. Chronic lymphocytic leukaemia. Nat Rev Dis Primers 2017; 3:16096. [PMID: 28102226 PMCID: PMC5336551 DOI: 10.1038/nrdp.2016.96] [Citation(s) in RCA: 287] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is a malignancy of CD5+ B cells that is characterized by the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues. Signalling via surface immunoglobulin, which constitutes the major part of the B cell receptor, and several genetic alterations play a part in CLL pathogenesis, in addition to interactions between CLL cells and other cell types, such as stromal cells, T cells and nurse-like cells in the lymph nodes. The clinical progression of CLL is heterogeneous and ranges from patients who require treatment soon after diagnosis to others who do not require therapy for many years, if at all. Several factors, including the immunoglobulin heavy-chain variable region gene (IGHV) mutational status, genomic changes, patient age and the presence of comorbidities, should be considered when defining the optimal management strategies, which include chemotherapy, chemoimmunotherapy and/or drugs targeting B cell receptor signalling or inhibitors of apoptosis, such as BCL-2. Research on the biology of CLL has profoundly enhanced our ability to identify patients who are at higher risk for disease progression and our capacity to treat patients with drugs that selectively target distinctive phenotypic or physiological features of CLL. How these and other advances have shaped our current understanding and treatment of patients with CLL is the subject of this Primer.
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Affiliation(s)
- Thomas J Kipps
- Division of Hematology-Oncology, Department of Medicine, Moores Cancer Centre, University of California, San Diego, 3855 Health Sciences Drive M/C 0820, La Jolla, California 92093, USA
| | - Freda K Stevenson
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Catherine J Wu
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carlo M Croce
- Department of Molecular Virology, Immunology and Medical Genetics, Ohio State University, Columbus, Ohio, USA
| | - Graham Packham
- Southampton Cancer Research UK Centre, Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - William G Wierda
- Department of Hematology, MD Anderson Cancer Centre, Houston, Texas, USA
| | - Susan O'Brien
- Division of Hematology, Department of Medicine, University of California, Irvine, California, USA
| | - John Gribben
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Kanti Rai
- CLL Research and Treatment Program, Feinstein Institute for Medical Research, Northwell Health, New Hyde Park, New York, USA
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Moccia AA, Zucca E, Ghielmini M. Is there a role for a maintenance rituximab in indolent lymphoproliferative diseases other than follicular lymphoma? Leuk Lymphoma 2016; 58:30-36. [PMID: 27813427 DOI: 10.1080/10428194.2016.1248963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Rituximab (R) is an anti-CD20 monoclonal antibody which has become an essential component for the treatment of B-cell lymphomas. When associated to chemotherapy it improves the outcome of the patients with diffuse large B-cell lymphoma, follicular lymphoma, and other lymphoproliferative diseases in comparison to chemotherapy alone. For patients with newly diagnosed follicular lymphoma achieving at least a partial response to initial immuno-chemotherapy, maintenance R was associated with an improvement in progression-free survival and a meta-analysis of randomized maintenance trials suggests an overall survival advantage. The role of maintenance R in other indolent diseases is less well-defined. In this article, we summarize the data available for this strategy in less frequent subtypes of indolent B-cell lymphomas.
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Affiliation(s)
- Alden A Moccia
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Emanuele Zucca
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Michele Ghielmini
- a Department of Medical Oncology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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40
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Delgado J, Montserrat E. Maintenance therapy in chronic lymphocytic leukaemia. LANCET HAEMATOLOGY 2016; 3:e399-400. [PMID: 27570083 DOI: 10.1016/s2352-3026(16)30081-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Julio Delgado
- Department of Haematology, Institute of Haematology and Oncology, University of Barcelona, Hospital Clínic, 08036 Barcelona, Spain
| | - Emili Montserrat
- Department of Haematology, Institute of Haematology and Oncology, University of Barcelona, Hospital Clínic, 08036 Barcelona, Spain.
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Sánchez-Ramón S, Dhalla F, Chapel H. Challenges in the Role of Gammaglobulin Replacement Therapy and Vaccination Strategies for Hematological Malignancy. Front Immunol 2016; 7:317. [PMID: 27597852 PMCID: PMC4993076 DOI: 10.3389/fimmu.2016.00317] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/05/2016] [Indexed: 12/13/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) are prone to present with antibody production deficits associated with recurrent or severe bacterial infections that might benefit from human immunoglobulin (Ig) (IVIg/SCIg) replacement therapy. However, the original IVIg trial data were done before modern therapies were available, and the current indications do not take into account the shift in the immune situation of current treatment combinations and changes in the spectrum of infections. Besides, patients affected by other B cell malignancies present with similar immunodeficiency and manifestations while they are not covered by the current IVIg indications. A potential beneficial strategy could be to vaccinate patients at monoclonal B lymphocytosis and monoclonal gammopathy of undetermined significance stages (for CLL and MM, respectively) or at B-cell malignancy diagnosis, when better antibody responses are attained. We have to re-emphasize the need for assessing and monitoring specific antibody responses; these are warranted to select adequately those patients for whom early intervention with prophylactic anti-infective therapy and/or IVIg is preferred. This review provides an overview of the current scenario, with a focus on prevention of infection in patients with hematological malignancies and the role of Ig replacement therapy.
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Affiliation(s)
- Silvia Sánchez-Ramón
- Department of Clinical Immunology and IdISSC, Hospital Clínico San Carlos, Madrid, Spain; Department of Microbiology I, Complutense University School of Medicine, Madrid, Spain
| | - Fatima Dhalla
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Clinical Immunology, John Radcliffe Hospital, Headington, Oxford, UK
| | - Helen Chapel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Department of Clinical Immunology, John Radcliffe Hospital, Headington, Oxford, UK
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Tam CS. Maintenance therapy in CLL: resolving the controversy. LANCET HAEMATOLOGY 2016; 3:e304-5. [PMID: 27374461 DOI: 10.1016/s2352-3026(16)30046-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Constantine S Tam
- Haematology Department, St Vincent's Hospital, Fitzroy, VIC, Australia; Haematology Department, Peter MacCallum Cancer Center, East Melbourne, VIC, Australia; University of Melbourne, Parkville, VIC, Australia.
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