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Jain N, Wierda WG, O'Brien S. Chronic lymphocytic leukaemia. Lancet 2024; 404:694-706. [PMID: 39068951 DOI: 10.1016/s0140-6736(24)00595-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/22/2024] [Accepted: 03/21/2024] [Indexed: 07/30/2024]
Abstract
The last decade has seen remarkable progress in our understanding of disease biology of chronic lymphocytic leukaemia (CLL) and the development of novel targeted therapies. Randomised clinical trials have reported improved progression-free survival and overall survival with targeted therapies compared with chemoimmunotherapy, and thereby the role of chemoimmunotherapy in todays' era for treatment of CLL is limited. Bruton tyrosine kinase (BTK) inhibitors, BCL2 inhibitors, and CD20 monoclonal antibodies have been established as appropriate therapy options for patients with CLL, both as the first-line treatment and in the treatment of relapsed or refractory CLL. Several ongoing phase 3 trials are exploring different combinations of targeted therapies, and the results of these trials might change the treatment framework in first-line treatment of CLL. Non-covalent BTK inhibitors, chimeric antigen receptor T-cell therapy, and other therapeutic strategies are being investigated in relapsed CLL. Some of the therapies used in relapsed CLL, such as non-covalent BTK inhibitors, are now being pursued in earlier lines of therapy, including first-line treatment of CLL.
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Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Division of Hematology/Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA, USA.
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2
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Nguyen-Khac F, Baron M, Guièze R, Feugier P, Fayault A, Raynaud S, Troussard X, Droin N, Damm F, Smagghe L, Susin S, Leblond V, Dartigeas C, Van den Neste E, Leprêtre S, Bernard OA, Roos-Weil D. Prognostic impact of genetic abnormalities in 536 first-line chronic lymphocytic leukaemia patients without 17p deletion treated with chemoimmunotherapy in two prospective trials: Focus on IGHV-mutated subgroups (a FILO study). Br J Haematol 2024; 205:495-502. [PMID: 38654616 DOI: 10.1111/bjh.19459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
The potential prognostic influence of genetic aberrations on chronic lymphocytic leukaemia (CLL) can vary based on various factors, such as the immunoglobulin heavy variable (IGHV) status. We conducted an integrative analysis on genetic abnormalities identified through cytogenetics and targeted next-generation sequencing in 536 CLL patients receiving first-line chemo(immuno)therapies (CIT) as part of two prospective trials. We evaluated the prognostic implications of the main abnormalities, with specific attention to their relative impact according to IGHV status. In the entire cohort, unmutated (UM)-IGHV, complex karyotype, del(11q) and ATM mutations correlated significantly with shorter progression-free survival (PFS). Focusing on the subset of mutated IGHV (M-IGHV) patients, univariate analysis showed that complex karyotype, del(11q), SF3B1 and SAMHD1 mutations were associated with significant lower PFS. The prognostic influence varied based on the patient's IGHV status, as these abnormalities did not affect outcomes in the UM-IGHV subgroup. TP53 mutations had no significant impact on outcomes in the M-IGHV subgroup. Our findings highlight the diverse prognostic influence of genetic aberrations depending on the IGHV status in symptomatic CLL patients receiving first-line CIT. The prognosis of gene mutations and cytogenetic abnormalities needs to be investigated with a compartmentalized methodology, taking into account the IGVH status of patients receiving first-line BTK and/or BCL2 inhibitors.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Female
- Middle Aged
- Aged
- Mutation
- Prognosis
- Immunoglobulin Heavy Chains/genetics
- Prospective Studies
- Chromosomes, Human, Pair 17/genetics
- Chromosome Deletion
- Adult
- Aged, 80 and over
- Immunoglobulin Variable Region/genetics
- Immunotherapy/methods
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
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Affiliation(s)
- Florence Nguyen-Khac
- Unité de Cytogénétique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
- Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, Centre de Recherche Des Cordeliers, INSERM, Sorbonne Université, Université Sorbonne Paris Cité, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Marine Baron
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Romain Guièze
- Hematology Department, Clermont-Ferrand University Hospital, Clermont Auvergne University, Clermont-Ferrand, France
| | - Pierre Feugier
- Department of Hematology, University Hospital of Nancy, Nancy, France
| | | | - Sophie Raynaud
- Laboratory of Hematology, University Hospital of Nice, Nice, France
| | | | - Nathalie Droin
- Inserm U1287, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | - Frederik Damm
- Department of Hematology, Oncology, and Cancer Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Luce Smagghe
- Unité de Cytogénétique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Santos Susin
- Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, Centre de Recherche Des Cordeliers, INSERM, Sorbonne Université, Université Sorbonne Paris Cité, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Véronique Leblond
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | | | - Eric Van den Neste
- Department of Hematology, Cliniques Universitaires Université Catholique de Louvain Saint-Luc, Bruxelles, Belgium
| | - Stéphane Leprêtre
- Department of Clinical Hematology, Centre Henri Becquerel, Rouen, France
| | - Olivier A Bernard
- Inserm U1170, Université Paris-Saclay, Gustave Roussy Cancer Campus, Villejuif, France
| | - Damien Roos-Weil
- Cell Death and Drug Resistance in Lymphoproliferative Disorders Team, Centre de Recherche Des Cordeliers, INSERM, Sorbonne Université, Université Sorbonne Paris Cité, Université Paris Descartes, Université Paris Diderot, Paris, France
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
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3
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Du J, Chen ZY, Gu XR, Wang T, Huang ZF. Bruton tyrosine kinase inhibitor-related atrial fibrillation and its implications in the treatment of B-cell lymphoma. Front Cardiovasc Med 2024; 11:1408983. [PMID: 39131702 PMCID: PMC11310794 DOI: 10.3389/fcvm.2024.1408983] [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: 03/29/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Adverse events of atrial fibrillation (AF) have been commonly reported in lymphoma patients in treating Bruton's tyrosine kinase inhibitors (BTKi). The incidence rate of AF can vary depending on the specific types of BTKi and the patient population. Totally 45 published studies have revealed that the overall incidence rate of AF is 5% (95% CI 4%-7%). By performing a subtype single-rate analysis, the second-generation BTKi shows a lower AF incidence rate and lower cardiovascular toxicity. In the subtype single-rate analysis, we conclude the different AF incidence rates of Ibrutinib (10%, 95% CI 7%-13%), Acalabrutinib (4%, 95% CI 1%-6%), Orelabrutinib (0%, 95% CI 0%-1%), and Zanubrutinib (0%, 95% CI 0%-1%). The comprehensive analysis of AF inspires us to better predict and manage AF and other cardiovascular events in treating lymphoma. Meticulous evaluation, collaboration between cardiologists and hematologists, and discovery of new biomarkers are essential for its management.
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Affiliation(s)
- Jun Du
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ze-Yu Chen
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Ran Gu
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Wang
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zou-Fang Huang
- Ganzhou Key Laboratory of Hematology, Department of Hematology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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4
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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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5
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Huang H, Liu Y, Zeng M, Chen X, Yin Y, Guo H, Yan Z, Lin J. Clinical analysis of hairy cell leukemia: the rare indolent hematological malignancy. Am J Transl Res 2024; 16:466-476. [PMID: 38463575 PMCID: PMC10918128 DOI: 10.62347/wfqm3371] [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: 11/05/2023] [Accepted: 01/30/2024] [Indexed: 07/29/2024]
Abstract
OBJECTIVE To analyze the clinical features, diagnosis and treatment and prognosis of the rare hairy cell leukemia (HCL), in order to provide new references for the clinical and basic research of HCL. METHODS The clinical data of 17 patients with HCL admitted to Fujian Medical University Union Hospital, the Affiliated Hospital of Putian University and the First Affiliated Hospital of Gannan Medical University from January 1, 2016 to July 1, 2023 were collected and retrospectively studied, and the clinical features, diagnosis and treatment effects and prognosis of patients with HCL were analyzed. The Kaplan-Meier method was used for survival analysis. Meanwhile, the latest literature from PubMed was retrieved to systematically discuss the research progress in the diagnosis and treatment of HCL. RESULTS In this study, there were 11 males and 6 females, the median age at diagnosis was 59.5 (30-81) years old, and the median time from the onset of clinical symptoms or signs to diagnosis was 4.5 (0.5-28.5) months. There were 9 cases (52.94%) with lymphoma B symptoms (fever, night sweating, and weight loss), 15 cases (88.24%) were accompanied by splenomegaly (3 cases of mild splenomegaly, 4 cases of moderate splenomegaly, and 8 cases of megasplenomegaly), the positive rate of BRAFV600E mutation is 76.47% (13/17). All patients in this study were treated, of which 11 were treated with Cladribine, 3 with Interferon, 2 with FC regimen, and 1 with R-CVP regimen + Cladribine. The median follow-up time was 39 (range, 2-83) months, 3 patients died, all due to failure of chemotherapy due to disease progression. The prognosis of HCL-v patients was significantly worse than that of cHCL patients (P=0.01), and there was no significant difference in the impact of different treatment regiments on the OS of HCL patients (P=0.328). CONCLUSION HCL is a rare clinically indolent hematological tumor, which is sensitive to Cladribine, with the emergence of precision treatments such as the novel molecular-targeted drugs and immunotherapy also plays an indispensable role in clinical practice of HCL.
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Affiliation(s)
- He Huang
- Department of Cardiovascular Medicine (Cardiology), The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Yanquan Liu
- Department of Hematology, The First Dongguan Affiliated Hospital of Guangdong Medical UniversityDongguan 523808, Guangdong, China
| | - Minjuan Zeng
- Department of Hematology, The First Dongguan Affiliated Hospital of Guangdong Medical UniversityDongguan 523808, Guangdong, China
| | - Xiaojun Chen
- Department of Hematology, The Affiliated Hospital of Putian UniversityPutian 351100, Fujian, China
| | - Yue Yin
- Fujian Institute of Hematology, Fujian Medical University Union HospitalFuzhou 350001, Fujian, China
| | - Huidong Guo
- Department of Pathology, The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Zhimin Yan
- Department of Hematology, The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Jie Lin
- Department of Intensive Medicine (Comprehensive ICU), The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
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6
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Huang H, Liu Y, Zeng M, Chen X, Yin Y, Guo H, Yan Z, Lin J. Clinical analysis of hairy cell leukemia: the rare indolent hematological malignancy. Am J Transl Res 2024; 16:466-476. [PMID: 38463575 PMCID: PMC10918128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/30/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE To analyze the clinical features, diagnosis and treatment and prognosis of the rare hairy cell leukemia (HCL), in order to provide new references for the clinical and basic research of HCL. METHODS The clinical data of 17 patients with HCL admitted to Fujian Medical University Union Hospital, the Affiliated Hospital of Putian University and the First Affiliated Hospital of Gannan Medical University from January 1, 2016 to July 1, 2023 were collected and retrospectively studied, and the clinical features, diagnosis and treatment effects and prognosis of patients with HCL were analyzed. The Kaplan-Meier method was used for survival analysis. Meanwhile, the latest literature from PubMed was retrieved to systematically discuss the research progress in the diagnosis and treatment of HCL. RESULTS In this study, there were 11 males and 6 females, the median age at diagnosis was 59.5 (30-81) years old, and the median time from the onset of clinical symptoms or signs to diagnosis was 4.5 (0.5-28.5) months. There were 9 cases (52.94%) with lymphoma B symptoms (fever, night sweating, and weight loss), 15 cases (88.24%) were accompanied by splenomegaly (3 cases of mild splenomegaly, 4 cases of moderate splenomegaly, and 8 cases of megasplenomegaly), the positive rate of BRAFV600E mutation is 76.47% (13/17). All patients in this study were treated, of which 11 were treated with Cladribine, 3 with Interferon, 2 with FC regimen, and 1 with R-CVP regimen + Cladribine. The median follow-up time was 39 (range, 2-83) months, 3 patients died, all due to failure of chemotherapy due to disease progression. The prognosis of HCL-v patients was significantly worse than that of cHCL patients (P=0.01), and there was no significant difference in the impact of different treatment regiments on the OS of HCL patients (P=0.328). CONCLUSION HCL is a rare clinically indolent hematological tumor, which is sensitive to Cladribine, with the emergence of precision treatments such as the novel molecular-targeted drugs and immunotherapy also plays an indispensable role in clinical practice of HCL.
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Affiliation(s)
- He Huang
- Department of Cardiovascular Medicine (Cardiology), The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Yanquan Liu
- Department of Hematology, The First Dongguan Affiliated Hospital of Guangdong Medical UniversityDongguan 523808, Guangdong, China
| | - Minjuan Zeng
- Department of Hematology, The First Dongguan Affiliated Hospital of Guangdong Medical UniversityDongguan 523808, Guangdong, China
| | - Xiaojun Chen
- Department of Hematology, The Affiliated Hospital of Putian UniversityPutian 351100, Fujian, China
| | - Yue Yin
- Fujian Institute of Hematology, Fujian Medical University Union HospitalFuzhou 350001, Fujian, China
| | - Huidong Guo
- Department of Pathology, The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Zhimin Yan
- Department of Hematology, The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
| | - Jie Lin
- Department of Intensive Medicine (Comprehensive ICU), The First Affiliated Hospital of Gannan Medical UniversityGanzhou 341000, Jiangxi, China
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Davids MS. Functional cure reported in CLL. Blood 2023; 142:1761-1763. [PMID: 37995104 DOI: 10.1182/blood.2023021954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023] Open
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8
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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9
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Hruba L, Das V, Hajduch M, Dzubak P. Nucleoside-based anticancer drugs: Mechanism of action and drug resistance. Biochem Pharmacol 2023; 215:115741. [PMID: 37567317 DOI: 10.1016/j.bcp.2023.115741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/13/2023]
Abstract
Nucleoside-based drugs, recognized as purine or pyrimidine analogs, have been potent therapeutic agents since their introduction in 1950, deployed widely in the treatment of diverse diseases such as cancers, myelodysplastic syndromes, multiple sclerosis, and viral infections. These antimetabolites establish complex interactions with cellular molecular constituents, primarily via activation of phosphorylation cascades leading to consequential interactions with nucleic acids. However, the therapeutic efficacy of these agents is frequently compromised by the development of drug resistance, a continually emerging challenge in their clinical application. This comprehensive review explores the mechanisms of resistance to nucleoside-based drugs, encompassing a wide spectrum of phenomena from alterations in membrane transporters and activating kinases to changes in drug elimination strategies and DNA damage repair mechanisms. The critical analysis in this review underlines complex interactions of drug and cell and also guides towards novel therapeutic strategies to counteract resistance. The development of targeted therapies, novel nucleoside analogs, and synergistic drug combinations are promising approaches to restore tumor sensitivity and improve patient outcomes.
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Affiliation(s)
- Lenka Hruba
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic
| | - Viswanath Das
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic
| | - Marian Hajduch
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic; Laboratory of Experimental Medicine, University Hospital, Olomouc 779 00, Czech Republic
| | - Petr Dzubak
- Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University in Olomouc, Olomouc, Czech Republic; Laboratory of Experimental Medicine, University Hospital, Olomouc 779 00, Czech Republic.
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10
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Miao Y, Sha Y, Xia Y, Qin S, Jiang R, Dai L, Shen H, Qiu T, Wu W, Qiu J, Yang Y, Ding C, Wu Y, Fan L, Xu W, Li J, Zhu H. Ibrutinib plus fludarabine, cyclophosphamide and rituximab (iFCR) as initial treatment in chronic lymphocytic leukemia/ small lymphocytic leukemia with or without TP53 aberrations: a prospective real-world study in Chinese cohort. Blood Cancer J 2023; 13:121. [PMID: 37558684 PMCID: PMC10412547 DOI: 10.1038/s41408-023-00890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/09/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Affiliation(s)
- Yi Miao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Yeqin Sha
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Yi Xia
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Shuchao Qin
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Rui Jiang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Luomengjia Dai
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Hui Shen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Tonglu Qiu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Wei Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Jingyan Qiu
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
| | - Yilian Yang
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
| | - Chongyang Ding
- Department of Nuclear Medicine, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
| | - Yujie Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Lei Fan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China
| | - Wei Xu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China.
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China.
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China.
| | - Jianyong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China.
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China.
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China.
| | - Huayuan Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 210029, Nanjing, Jiangsu, China.
- Pukou Chronic Lymphocytic Leukemia (CLL) Center, Pukou division of Jiangsu Province Hospital, 211800, Nanjing, Jiangsu, China.
- Jiangsu Key Lab of Cancer Biomarkers, Prevention and Treatment, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing Medical University, 210029, Nanjing, Jiangsu, China.
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11
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Michallet AS, Letestu R, Le Garff-Tavernier M, Campos L, Ticchioni M, Dilhuydy MS, Morisset S, Rouille V, Mahé B, Laribi K, Villemagne B, Ferrant E, Tournilhac O, Delmer A, Molina L, Leblond V, Tomowiak C, de Guibert S, Orsini-Piocelle F, Banos A, Carassou P, Cartron G, Fornecker LM, Ysebaert L, Dartigeas C, Truchan-Graczyk M, Vilque JP, Schleinitz TA, Cymbalista F, Leprêtre S, Lévy V, Nguyen-Khac F, Feugier P. A fixed-duration immunochemotherapy approach in CLL: 5.5-year results from the phase 2 ICLL-07 FILO trial. Blood Adv 2023; 7:3936-3945. [PMID: 37026799 PMCID: PMC10410135 DOI: 10.1182/bloodadvances.2022009594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023] Open
Abstract
In previously untreated, medically fit patients with chronic lymphocytic leukemia (CLL), research is focused on developing fixed-duration strategies to improve long-term outcomes while sparing patients from serious toxicities. The ICLL-07 trial evaluated a fixed-duration (15-month) immunochemotherapy approach in which after obinutuzumab-ibrutinib induction for 9 months, patients (n = 10) in complete remission (CR) with bone marrow (BM) measurable residual disease (MRD) <0.01% continued only ibrutinib 420 mg/day for 6 additional months (I arm), whereas the majority (n = 115) received up to 4 cycles of fludarabine/cyclophosphamide-obinutuzumab 1000 mg alongside the ibrutinib (I-FCG arm). Primary analysis at month 16 showed that 84 of 135 (62.2%) patients enrolled achieved CR with a BM MRD <0.01%. Here, we report follow-up at median 63 months. Peripheral blood (PB) MRD was assessed 6 monthly beyond the end of treatment using a highly sensitive (10-6) flow cytometry technique. In the I-FCG arm, the PB MRD <0.01% rate (low-level positive <0.01% or undetectable with limit of detection ≤10-4) in evaluable patients was still 92.5% (74/80) at month 40 and 80.6% (50/62) at month 64. No differences in the PB MRD status were apparent per to the IGHV mutational status. In the overall population, 4-year progression-free and overall survival rates were 95.5% and 96.2%, respectively. Twelve deaths occurred overall. Fourteen serious adverse events occurred beyond the end of treatment. Thus, our fixed-duration immunochemotherapy approach produced deep and sustained PB MRD responses, high survival rates, and low long-term toxicity. A randomized trial is needed to compare our immunochemotherapy approach with a chemotherapy-free strategy. This trial was registered at www.clinicaltrials.gov as #NCT02666898.
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Affiliation(s)
| | - Rémi Letestu
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
| | | | - Lydia Campos
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
| | | | | | | | - Valérie Rouille
- Department of Hematology, CHU Montpellier, Montpellier, France
| | - Béatrice Mahé
- Department of Hematology, Nantes University Hospital, Nantes, France
| | - Kamel Laribi
- Department of Hematology, CH Le Mans, Le Mans, France
| | | | - Emmanuelle Ferrant
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
| | - Olivier Tournilhac
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
| | - Alain Delmer
- Department of Hematology, CHU Reims, Reims, France
| | - Lysiane Molina
- Department of Hematology, CHU Grenoble, La Tronche, France
| | - Véronique Leblond
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | | | | | | | - Anne Banos
- Department of Hematology, CH Côte Basque, Bayonne, France
| | | | - Guillaume Cartron
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
| | | | - Loic Ysebaert
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | | | | | - Jean-Pierre Vilque
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
| | | | | | - Stéphane Leprêtre
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
| | - Vincent Lévy
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
| | | | - Pierre Feugier
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
| | - French Innovative Leukemia Organization (FILO) CLL group
- Department of Hematology, Centre Léon Bérard, Lyon, France
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
- Department of Hematology Biology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
- Department of Immunology, CHU Nice, Nice, France
- Department of Hematology, CHU Bordeaux, Pessac, France
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Nantes University Hospital, Nantes, France
- Department of Hematology, CH Le Mans, Le Mans, France
- Department of Hematology, CHD Vendée, La Roche-sur-Yon, France
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
- Department of Hematology, CHU Reims, Reims, France
- Department of Hematology, CHU Grenoble, La Tronche, France
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology, CHU Poitiers, Poitiers, France
- Department of Hematology, CHU Rennes, Rennes, France
- Hematology Service, CH Annecy, Annecy, France
- Department of Hematology, CH Côte Basque, Bayonne, France
- Department of Hematology, CH Metz, Metz, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
- Department of Hematology, Strasbourg University Hospital, Strasbourg, France
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
- Department of Hematology, CHU Tours, Hôpital Bretonneau, Tours, France
- Department of Hematology, CHU Angers, Angers, France
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
- Department of Hematology, Institut Paoli Calmettes, Marseille, Marseille France
- Department of Hematology, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
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12
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Xue T, Kong X, Ma L. Trends in the Epidemiology of Pneumocystis Pneumonia in Immunocompromised Patients without HIV Infection. J Fungi (Basel) 2023; 9:812. [PMID: 37623583 PMCID: PMC10455156 DOI: 10.3390/jof9080812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/19/2023] [Accepted: 07/19/2023] [Indexed: 08/26/2023] Open
Abstract
The increasing morbidity and mortality of life-threatening Pneumocystis pneumonia (PCP) in immunocompromised people poses a global concern, prompting the World Health Organization to list it as one of the 19 priority invasive fungal diseases, calling for increased research and public health action. In response to this initiative, we provide this review on the epidemiology of PCP in non-HIV patients with various immunodeficient conditions, including the use of immunosuppressive agents, cancer therapies, solid organ and stem cell transplantation, autoimmune and inflammatory diseases, inherited or primary immunodeficiencies, and COVID-19. Special attention is given to the molecular epidemiology of PCP outbreaks in solid organ transplant recipients; the risk of PCP associated with the increasing use of immunodepleting monoclonal antibodies and a wide range of genetic defects causing primary immunodeficiency; the trend of concurrent infection of PCP in COVID-19; the prevalence of colonization; and the rising evidence supporting de novo infection rather than reactivation of latent infection in the pathogenesis of PCP. Additionally, we provide a concise discussion of the varying effects of different immunodeficient conditions on distinct components of the immune system. The objective of this review is to increase awareness and knowledge of PCP in non-HIV patients, thereby improving the early identification and treatment of patients susceptible to PCP.
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Affiliation(s)
- Ting Xue
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Xiaomei Kong
- NHC Key Laboratory of Pneumoconiosis, Key Laboratory of Prophylaxis and Treatment and Basic Research of Respiratory Diseases of Shanxi Province, Shanxi Province Key Laboratory of Respiratory, Department of Respiratory and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Liang Ma
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD 20892, USA
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13
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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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14
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Hänsel L, Schumacher J, Denis B, Hamane S, Cornely OA, Koehler P. How to diagnose and treat a non-HIV patient with Pneumocystis jirovecii pneumonia (PCP)? Clin Microbiol Infect 2023:S1198-743X(23)00186-6. [PMID: 37086781 DOI: 10.1016/j.cmi.2023.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Pneumocystis jirovecii Pneumonia (PCP) incidence is increasing in non-HIV infected patients. In contrast to PCP in patients infected with HIV, diagnosis is often delayed, and illness is associated with an increased mortality. OBJECTIVE To provide a comprehensive review of clinical presentation, risk factors, diagnostic strategies, and treatment options of PCP in non-HIV-infected patients. SOURCES Web-based literature review on PCP for trials, meta-analyses and systematic reviews using PubMed. Restriction to English language was applied. CONTENT Common underlying conditions in non-HIV-infected patients with PCP are haematological malignancies, autoimmune and inflammatory diseases, solid organ or haematopoietic stem cell transplant and prior exposure to corticosteroids. New risk groups include patients receiving monoclonal antibodies and immunomodulating therapies. Non-HIV-infected patients with PCP present with rapid onset and progression of pneumonia, increased duration of hospitalization and a significantly higher mortality rate than patients infected with HIV. PCP is diagnosed by a combination of clinical symptoms, radiological and mycological features. Immunofluorescence microscopy from bronchoalveolar lavage (BAL) or PCR testing CT imaging and evaluation of the clinical presentation are required. The established treatment regime consists of trimethoprim and sulfamethoxazole. IMPLICATIONS While the number of patients immunosuppressed for other causes than HIV is increasing, a simultaneous rise in PCP incidence is observed. In the group of non-HIV-infected patients, a rapid onset of symptoms, a more complex course, and a higher mortality rate are recorded. Therefore, time to diagnosis must be as short as possible to initiate effective therapy promptly. This review aims to raise awareness of PCP in an increasingly affected at-risk group and provide clinicians with a practical guide for efficient diagnosis and targeted therapy. Furthermore, it intends to display current inadequacies in research on the topic of PCP.
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Affiliation(s)
- Luise Hänsel
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Jana Schumacher
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | - Blandine Denis
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Samia Hamane
- Department of infectious diseases, Saint Louis and Lariboisière Hospitals, APHP, Paris, France, Excellence Centre for Medical Mycology (ECMM), Paris, France
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinical Trials Centre Cologne (ZKS Köln), Cologne, Germany
| | - Philipp Koehler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), Cologne, Germany; University of Cologne, Faculty of Medicine, and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD) and Excellence Center for Medical Mycology (ECMM), Cologne, Germany.
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15
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Wierda WG, Kipps TJ, Al-Sawaf O, Chyla B, Biondo JML, Mun Y, Jiang Y, Seymour JF. Utility of measurable residual disease for predicting treatment outcomes with BCR- and BCL2-Targeted therapies in patients with CLL. Leuk Lymphoma 2022; 63:2765-2784. [PMID: 35983732 DOI: 10.1080/10428194.2022.2098291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/27/2022] [Indexed: 12/14/2022]
Abstract
Inhibitors targeting B-cell receptor (BCR) signaling pathway proteins and B-cell lymphoma-2 (BCL2) in chronic lymphocytic leukemia (CLL) are recommended in the first-line and relapsed/refractory disease settings. Measurable residual disease (MRD) is an important prognostic tool in patients treated with the BCL2-targeted agent, venetoclax. We explored the relationship between MRD status and progression-free (PFS)/overall survival (OS) in patients with CLL, following treatment with novel BCR- and BCL2-targeted agents. Compared with chemoimmunotherapy, higher rates of undetectable (u)MRD were achieved with BCL2-targeted therapies; achieving uMRD status was associated with longer PFS and OS than MRD-positivity. Continuous treatment with BCR-targeted agents did not achieve uMRD status in many patients, and outcomes were not correlated with uMRD status. Future clinical trials of targeted treatment combinations could be designed to demonstrate uMRD as a treatment objective, and allow a response-driven, personalized strategy to optimize treatment and improve OS outcomes.
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Affiliation(s)
| | | | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne Aachen Cologne Bonn Düsseldorf, German CLL Study Group, University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Yong Mun
- Genentech, Inc., South San Francisco, CA, USA
| | | | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
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16
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Alu A, Lei H, Han X, Wei Y, Wei X. BTK inhibitors in the treatment of hematological malignancies and inflammatory diseases: mechanisms and clinical studies. J Hematol Oncol 2022; 15:138. [PMID: 36183125 PMCID: PMC9526392 DOI: 10.1186/s13045-022-01353-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Bruton's tyrosine kinase (BTK) is an essential component of multiple signaling pathways that regulate B cell and myeloid cell proliferation, survival, and functions, making it a promising therapeutic target for various B cell malignancies and inflammatory diseases. Five small molecule inhibitors have shown remarkable efficacy and have been approved to treat different types of hematological cancers, including ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and orelabrutinib. The first-in-class agent, ibrutinib, has created a new era of chemotherapy-free treatment of B cell malignancies. Ibrutinib is so popular and became the fourth top-selling cancer drug worldwide in 2021. To reduce the off-target effects and overcome the acquired resistance of ibrutinib, significant efforts have been made in developing highly selective second- and third-generation BTK inhibitors and various combination approaches. Over the past few years, BTK inhibitors have also been repurposed for the treatment of inflammatory diseases. Promising data have been obtained from preclinical and early-phase clinical studies. In this review, we summarized current progress in applying BTK inhibitors in the treatment of hematological malignancies and inflammatory disorders, highlighting available results from clinical studies.
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Affiliation(s)
- Aqu Alu
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hong Lei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China.
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17
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St-Pierre F, Ma S. Use of BTK Inhibitors in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): A Practical Guidance. Blood Lymphat Cancer 2022; 12:81-98. [PMID: 35911566 PMCID: PMC9325877 DOI: 10.2147/blctt.s326627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/01/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment landscape of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has changed significantly since the development of oral Bruton’s tyrosine kinase (BTK) inhibitors. While chemoimmunotherapy was previously the standard of care for first-line treatment, BTK inhibitors have proven to be a highly effective and safe therapeutic option for CLL/SLL, and now constitute one of the preferred first-line options. Ibrutinib, the first approved covalent BTK inhibitor in CLL/SLL, has the most long-term data supporting its efficacy in CLL/SLL treatment although is associated with increased risk of cardiovascular and hemorrhage adverse events due to off-target kinase inhibition. The second-generation covalent BTK inhibitors, including acalabrutinib and zanubrutinib, are more selective to BTK with less off-target effects. Resistance to covalent BTK inhibitors may emerge over time due to mutations in BTK and downstream kinases. Novel non-covalent BTK inhibitors currently being studied are showing promising activities to overcome such resistance. In this review, we discuss the role of BTK inhibitors in treatment of CLL/SLL, review the data that led to approval of BTK inhibitors in CLL/SLL, outline the toxicity profile of each approved BTK inhibitor and management, and give practical guidance on how to select the most appropriate agent for treatment.
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Affiliation(s)
- Frédérique St-Pierre
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Shuo Ma
- Department of Medicine, Division of Hematology/Oncology and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Correspondence: Shuo Ma, Division of Hematology-Oncology, Department of Medicine, Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Tel +1 312-695-0990, Email
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18
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Tian Z, Liu M, Fang X, Zhou X, Li P, Li Y, Zhang L, Liu F, Zhang Y, Wang X. Distinct Age-Related Clinical Features and Risk Assessment in Chinese With Chronic Lymphocytic Leukemia. Front Oncol 2022; 12:885150. [PMID: 35646669 PMCID: PMC9135454 DOI: 10.3389/fonc.2022.885150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/19/2022] [Indexed: 12/31/2022] Open
Abstract
The biological and clinical features of chronic lymphocytic leukemia (CLL) exhibited profound heterogeneity across Chinese and patients of predominately European descent. However, the age-related peculiarities and risk assessment of Chinese CLL patients remained ill-defined. The present study demonstrated that CLL patients were characterized by the earlier age at onset in China (median age at diagnosis: 63 years old) than in the United States (median age at diagnosis: 69 years old). Young patients from Shandong Provincial Hospital CLL database displayed prolonged overall survival than the Surveillance, Epidemiology, and End Results cohort. Furthermore, among Chinese CLL patients, young patients showed an increased relapse rate compared with elderly patients. To optimize the risk assessment of CLL patients, novel risk score models named PR-Score and HBG-Score were developed for predicting the outcomes of young and elderly CLL patients respectively. The neonatal survival prediction systems were superior to international prognostic index for CLL (CLL-IPI) and Binet stage in assessing the overall survival and progression free survival of CLL patients. The analyses highlighted refinement of risk evaluation for CLL patients in different age groups, providing insights into individualized diagnosis and treatment of CLL.
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Affiliation(s)
- Zheng Tian
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ming Liu
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiangxiang Zhou
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Peipei Li
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ying Li
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lingyan Zhang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Fang Liu
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ya Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.,School of Medicine, Shandong University, Jinan, China.,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, China.,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, China.,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China
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19
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New Treatment Options for Newly-Diagnosed and Relapsed Chronic Lymphocytic Leukemia. Curr Treat Options Oncol 2022; 23:775-795. [PMID: 35357653 DOI: 10.1007/s11864-022-00974-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT The better understanding of the biology of chronic lymphocytic leukemia (CLL) gained over the past decade has led to the development and introduction of several targeted drugs, with an demonstrable improvement in the prognosis for this currently incurable condition. Currently, Bruton's tyrosine kinase (BTK) inhibitors, phosphoinositide 3-kinase (PI3K) inhibitors, venetoclax, and CD20 monoclonal antibodies are the key elements in the treatment of both previously untreated and relapsed/refractory CLL patients. Ibrutinib was the first BTK inhibitor approved for clinical use, and showed excellent efficacy and an acceptable safety profile. Following this, the better-tolerated second-generation irreversible BTK inhibitors acalabrutinib and zanubrutinib have been introduced for the treatment of lymphoid malignancies, and acalabrutinib was approved for CLL. When used as single drugs, BTK inhibitors are given continuously until unacceptable toxicity or disease progression; however, when combined with venetoclax and/or CD20 antibodies, they induce deeper response and can be given for a limited time. Recently, promising new reversible BTK inhibitors pirtobrutinib and nemtabrutinib were discovered, and these seem to be more active and better tolerated than their irreversible predecessors. However, they are in an early phase of development and are not currently approved for CLL. The phosphatidylinositol 3-kinase (PI3K) inhibitors idelalisib and duvelisib are highly effective in patients with relapsed CLL, including high-risk disease. The major limitations for their use are adverse events, mostly of autoimmune origin (hepatitis, enteritis/colitis, and pneumonitis). Otherwise, cellular therapies like allogeneic hematopoietic stem cell transplantation and chimeric antigen receptor (CAR) T cells and bispecific monoclonal antibodies offer promise for patients who have failed BTK inhibitors and venetoclax treatment. In the coming years, it is likely that novel targeted therapies will replace immunochemotherapy regimens in most patients.
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20
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Minici C, Testoni S, Della-Torre E. B-Lymphocytes in the Pathophysiology of Pancreatic Adenocarcinoma. Front Immunol 2022; 13:867902. [PMID: 35359944 PMCID: PMC8963963 DOI: 10.3389/fimmu.2022.867902] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Pancreatic adenocarcinoma is highly infiltrated by B lymphocytes but the relevance of these immune cells in tumor development has been surprisingly overlooked until recently. Based on available evidence from other solid tumors, interaction between B lymphocytes and neoplastic cells is probably not uniformly stimulatory or inhibitory. Although presentation of tumor antigens to T cells and production of antitumor immunoglobulins might intuitively suggest a prominent tumor suppressive activity, specific subsets of B lymphocytes can secrete growth factors for neoplastic cells and immunosuppressive cytokines thus promoting escape from immunosurveillance and cancer progression. Because many of these mechanisms might also be implicated in the development of PDAC, and immune-modulation of B-cell activity is nowadays possible at different levels, determining the role of B-lymphocytes in this lethal cancer becomes of utmost importance to design novel therapeutic strategies. This review aims to discuss the emerging role of B cells in PDAC tumorigenesis, progression, and associated stromal reaction.
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Affiliation(s)
- Claudia Minici
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Emanuel Della-Torre
- Università Vita-Salute San Raffaele, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS San Raffaele Scientific Institute, Milan, Italy
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21
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Csanádi M, Ágh T, Tordai A, Tapprich C, Vokó Z, Stamatopoulos K. Secondary primary malignancies after treatment with chemo-immunotherapy in treatment-naïve patients with CLL: a systematic literature review. Expert Rev Hematol 2022; 15:273-284. [PMID: 35168449 DOI: 10.1080/17474086.2022.2042246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES In chronic lymphocytic leukemia (CLL), therapy-related cytotoxicity and the resulting immunodeficiency are thought to contribute to the development of secondary primary malignancies (SPM). Here we analyzed clinical trial data on the occurrence of SPM following chemo-immunotherapy (CIT) regimens in treatment-naïve CLL patients. METHODS A systematic literature search was conducted covering multiple databases between 2003-2019. Data from relevant clinical trials on the proportion of patients with SPMs were extracted. Then the number of SPM patients/person-years was calculated by taking into account the trials' follow-up time. Finally, a random-effects meta-analysis to pool the rates from individual studies was performed. RESULTS We identified 22 studies reporting SPM data available for analysis. Random-effects meta-analysis estimated that the number of SPM patients/1000 person-years was 24 (95%CI: 19-29). Results from trials with cancer-specific data indicated 19 (95%CI: 14-26) solid and 9 (95%CI: 6-12) hematological SPM patients/1000 person-years. These estimations did not change significantly when sub-groups were analysed by CIT regimens. CONCLUSION Although pooling data with the intention to analyze adverse event rates is challenging, our study concluded that in case of CIT regimens, SPM should be considered an important adverse outcome. Different regimens showed similar trends; however, other clinical and demographic factors have a profound impact in this respect.
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Affiliation(s)
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
| | - Attila Tordai
- Department of Transfusion Medicine, Semmelweis University, Budapest, Hungary
| | | | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary.,Center for Health Technology Assessment, Semmelweis University, Hungary
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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22
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Lévy V, Delmer A, Cymbalista F. Frontline treatment in CLL: the case for time-limited treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:59-67. [PMID: 34889444 PMCID: PMC8791103 DOI: 10.1182/hematology.2021000233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Over the last decade, the advent of Bruton tyrosine kinase inhibitors (BTKi) has profoundly modified the therapeutic strategy in chronic lymphocytic leukemia (CLL), introducing the concept of treatment until progression. Initially, the bcl-2 inhibitor venetoclax (VEN) was used as a single agent and then was rapidly combined in VEN-based regimens associated with either anti-CD20 or with BTKi. These regimens yielded a high rate of complete remission, leading to their use as a fixed duration treatment. The decision between continuous treatment with BTKi and VEN-based combinations relies mostly on comorbidities, comedications, and patient/physician preferences. Notably, with BTKi, cardiovascular comorbidities, hypertension, and potential pharmacological interactions should be carefully evaluated. On the other hand, the risk of tumor lysis syndrome with VEN should be monitored at treatment initiation. TP53 alteration and IGHV mutational status should also be assessed, as they remain important for therapeutic decisions. Fit patients with a TP53 wild type and IGHV-mutated CLL may still benefit from fludarabine-cyclophosphamide-rituximab chemoimmunotherapy (CIT), as it may result in a very long remission duration. VEN-based treatments are well tolerated, and no additional toxicity has been observed when combined with anti-CD20 or BTKi. The 1-year fixed-duration association of VEN plus obinutuzumab was evaluated in frontline for older adult patients. Nonetheless, considering the favorable outcome, an extension of indication for fit younger patients is expected. The association of VEN and BTKi is promising, even if the follow-up is still short. It is currently being tested against CIT, BTKi continuous treatment, and VEN plus anti-CD20.
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Affiliation(s)
- Vincent Lévy
- Département de Recherche Clinique, Hôpital Avicenne AP-HP, Université Sorbonne Paris Nord, Bobigny, France, and INSERM CRESS-UMR 1153, Hôpital Saint Louis, Paris, France
| | - Alain Delmer
- Hematology Department, Reims University Hospital and Reims Champagne Ardenne University, Reims, France
| | - Florence Cymbalista
- Hematology Biology, Hôpital Avicenne, AP-HP, Université Sorbonne Paris Nord, Bobigny, France, and INSERM UMR 978, Bobigny, France
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23
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Jain N, Thompson P, Burger J, Ferrajoli A, Takahashi K, Estrov Z, Borthakur G, Bose P, Kadia T, Pemmaraju N, Sasaki K, Konopleva M, Jabbour E, Garg N, Wang X, Kanagal-Shamanna R, Patel K, Wang W, Jorgensen J, Wang S, Lopez W, Ayala A, Plunkett W, Gandhi V, Kantarjian H, O'Brien S, Keating M, Wierda WG. Ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) regimen for chronic lymphocytic leukemia (CLL) with mutated IGHV and without TP53 aberrations. Leukemia 2021; 35:3421-3429. [PMID: 34007049 DOI: 10.1038/s41375-021-01280-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/20/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
Chemoimmunotherapy with combined fludarabine, cyclophosphamide and rituximab (FCR) has been an effective treatment for patients with chronic lymphocytic leukemia (CLL). We initiated a phase II trial for previously untreated patients with CLL with mutated IGHV and absence of del(17p)/TP53 mutation. Patients received ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) for three cycles. Patients who achieved complete remission (CR)/CR with incomplete count recvoery (CRi) with marrow undetectable measurable residual disease (U-MRD) received additional nine cycles of ibrutinib with three cycles of obinutuzumab; all others received nine additional cycles of ibrutinib and obinutuzumab. Patients in marrow U-MRD remission after cycle 12 discontinued all treatment, including ibrutinib. Forty-five patients were treated. The median follow-up is 41.3 months. Among the total 45 treated patients, after three cycles, 38% achieved CR/CRi and 87% achieved marrow U-MRD. After cycle 12, the corresponding numbers were 67% and 91%, respectively. Overall, 44/45 (98%) patients achieved marrow U-MRD as best response. No patient had CLL progression. The 3-year progression-free survival (PFS) and overall survival (OS) were 98% and 98%, respectively. Per trial design, all patients who completed cycle 12 discontinued ibrutinib, providing for a time-limited therapy. Grade 3-4 neutropenia and thrombocytopenia occurred in 58% and 40% patients, respectively. The iFCG regimen with only 3 cycles of chemotherapy is an effective, time-limited regimen for patients with CLL with mutated IGHV and without del(17p)/TP53 mutation.
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MESH Headings
- Adenine/administration & dosage
- Adenine/analogs & derivatives
- Adult
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor
- Cyclophosphamide/administration & dosage
- Female
- Follow-Up Studies
- Humans
- Immunoglobulin Heavy Chains/genetics
- Immunoglobulin Variable Region/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Mutation
- Piperidines/administration & dosage
- Prognosis
- Survival Rate
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Garg
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wanda Lopez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ana Ayala
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Plunkett
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Varsha Gandhi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Michael Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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24
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Chen L, Ji N, Zhang M, Chen W. The Influence of Wuzhi Capsule on the Pharmacokinetics of Cyclophosphamide. Recent Pat Anticancer Drug Discov 2021; 17:195-203. [PMID: 34758719 DOI: 10.2174/1574892816666211110152119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/15/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cyclophosphamide is approved for the treatment of a variety of tumors, yet the use of cyclophosphamide is limited by kidney and liver toxicity. In the clinic, the Wuzhi capsule is approved to attenuate cyclophosphamide toxicity in the kidney and liver. OBJECTIVE We aimed to investigate the effects of the principal ingredients of Wuzhi capsule, schisandrin A (SIA) and schisantherin A (STA), on the pharmacokinetics of cyclophosphamide. METHODS The essential pharmacokinetic data and physicochemical parameters of SIA, STA, and cyclophosphamide were collected. Physiologically based pharmacokinetic (PBPK) models of SIA, STA, and cyclophosphamide were built in Simcyp Simulator and verified using published clinical pharmacokinetic data. The verified PBPK models were used to predict potential herb-drug interactions (HDIs) between cyclophosphamide and SIA and STA in cancer patients. RESULTS The area under the plasma concentration-time curve (AUC) of cyclophosphamide was increased by 18% and 1% when co-administered with STA and SIA at a single dose, respectively, and increased by 301% and 29% when co-administered with STA and SIA at multiple doses, respectively. The maximum concentration (Cmax) of cyclophosphamide was increased by 75% and 7% when co-administered with STA and SIA at multiple doses, respectively. CONCLUSION The AUC and Cmax of cyclophosphamide were increased when cyclophosphamide was combined with the Wuzhi capsule, compared to cyclophosphamide alone. Our study shows that the adverse drug reactions and toxicity of cyclophosphamide should be closely monitored and an effective dosage adjustment of cyclophosphamide may need to be considered when co-administered with the Wuzhi capsule.
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Affiliation(s)
- Lu Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing. China
| | - Ning Ji
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY. United States
| | - Min Zhang
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing. China
| | - Wanyi Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing. China
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25
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Thompson PA. BTK Inhibitors Combined With Chemoimmunotherapy in CLL - The Best of Both Worlds? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:205-209. [PMID: 34774461 DOI: 10.1016/j.clml.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/08/2021] [Accepted: 09/16/2021] [Indexed: 11/27/2022]
Abstract
Chemoimmunotherapy (CIT) remains a standard-of-care in many regions for first line (1L) therapy of CLL. In fit patients, fludarabine, cyclophosphamide, and rituximab (FCR) has the advantage of achieving undetectable measurable residual disease (MRD) with time-limited treatment and prolonged treatment-free remissions with a plateau on the PFS curve, but have several limitations, most notably the inferior PFS and survival outcomes for patients with unmutated IGHV compared to ibrutinib + rituximab seen in the E1912 study and a risk for long-term toxicities such as therapy-related myeloid neoplasms. Given the nonoverlapping toxicity profile with CIT and its efficacy in patients with high risk genomics, ibrutinib is a potentially useful agent to combine with CIT, with the aim of achieving deep and durable remissions, with time-limited treatment. Three recent phase 2 studies have combined ibrutinib with chemoimmunotherapy, utilizing different approaches in terms of patient selection, sequencing and duration of therapy and choice of monoclonal antibody. These studies all demonstrated favorable toxicity profiles and higher rates of undetectable MRD than with any other previously utilized 1L regimen. This review will focus on this novel treatment approach in CLL.
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The M.D. Anderson Cancer Center, Houston, TX.
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26
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Non-Covalent BTK Inhibitors-The New BTKids on the Block for B-Cell Malignancies. J Pers Med 2021; 11:jpm11080764. [PMID: 34442408 PMCID: PMC8400141 DOI: 10.3390/jpm11080764] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022] Open
Abstract
The B-cell receptor signalling pathway plays a critical role in development of B-cell malignancies, and the central role of Bruton’s tyrosine kinase (BTK) activation in this pathway provides compelling rationale for BTK inhibition as a therapeutic strategy for these conditions. Covalent BTK inhibitors (BTKi) have transformed the treatment landscape of B-cell malignancies, but adverse events and treatment resistance have emerged as therapeutic challenges, with the majority of patients eventually discontinuing treatment due to toxicity or disease progression. Non-covalent BTKi have alternative mechanisms of binding to BTK than covalent BTKi, and therefore offer a therapeutic alternative for patients with B-cell malignancies, including those who have been intolerant to, or experienced disease progression during treatment with a covalent BTKi. Here, we summarise the clinical data, adverse events and mechanisms of resistance observed with covalent BTKi and describe the emerging data for non-covalent BTKi as a novel treatment for B-cell malignancies.
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27
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A fixed-duration, measurable residual disease-guided approach in CLL: follow-up data from the phase 2 ICLL-07 FILO trial. Blood 2021; 137:1019-1023. [PMID: 33167024 DOI: 10.1182/blood.2020008164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/07/2020] [Indexed: 11/20/2022] Open
Abstract
Trials assessing first-line, fixed-duration approaches in chronic lymphocytic leukemia (CLL) are yielding promising activity, but few long-term data are available. We report follow-up data from a phase 2 trial (ICLL07 FILO) in previously untreated, medically fit patients (N = 135). Patients underwent obinutuzumab-ibrutinib induction for 9 months; then, following evaluation (N = 130 evaluable), those in complete remission and with bone marrow measurable residual disease (BM MRD) <0.01% (n = 10) received ibrutinib for 6 additional months; those in partial remission and/or with BM MRD ≥0.01%, the majority (n = 120), also received 4 cycles of immunochemotherapy (fludarabine/cyclophosphamide-obinutuzumab). Beyond end of treatment, responses were assessed every 3 month and peripheral blood MRD every 6 months. At median follow-up 36.7 months from treatment start, progression-free and overall survival rates (95% confidence interval) at 3 years were 95.7% (92.0% to 99.5%) and 98% (95.1% to 100%), respectively. Peripheral blood MRD <0.01% rates were 97%, 96%, 90%, 84%, and 89% at months 16, 22, 28, 34, and 40, respectively. No new treatment-related or serious adverse event occurred beyond end of treatment. Thus, in previously untreated, medically fit patients with CLL, a fixed-duration (15 months), MRD-guided approach achieved high survival rates, a persistent MRD benefit beyond the end of treatment, and low long-term toxicity. This trial was registered at www.clinicaltrials.gov as #NCT02666898.
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Time-limited, Combined Regimen in Chronic Lymphocytic Leukemia: A Promising Strategy to Achieve a Drug Holiday. Curr Med Sci 2021; 41:431-442. [PMID: 34181208 DOI: 10.1007/s11596-021-2385-3] [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: 04/22/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
Chemoimmunotherapy (CIT) is defined as standard first line treatment for chronic lymphocytic leukemia (CLL) patients while patients with unfavorable biological characteristics such as unmutated immunoglobulin heavy chain (UM-IGHV) and TP53 aberration failed to benefit from it. The emergency of the small molecular targeted agents including Bruton's tyrosine kinase (BTK) inhibitor (BTKi) leads to a brand-new era, from a CIT to a chemo-free era in CLL. However, the treatment of target agents is not enough to attain a deep remission and high rate of complete remission (CR), especially in patients with high risks. The long duration brought about problems, such as cost, drug resistance and toxicity. To benefit CLL in progression free survival (PFS) and long-term remission, exploration of time-limited therapies, mainly with BTKi plus CIT and BCL2i based combination therapy has become a mainstream in clinical trials. The time-limited combination therapy shed light on the promising potentiality to attain sustainable deep remission and partly overcame the risk factors, although long term follow-up is required to consolidate the conclusion. In this review, we intend to introduce key results of clinical trials with combination therapy, discuss the achievements and limitations and put forward future direction for clinical trial design in this field.
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Ahn IE, Brown JR. Targeting Bruton's Tyrosine Kinase in CLL. Front Immunol 2021; 12:687458. [PMID: 34248972 PMCID: PMC8261291 DOI: 10.3389/fimmu.2021.687458] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/18/2021] [Indexed: 01/19/2023] Open
Abstract
Targeting the B-cell receptor signaling pathway through BTK inhibition proved to be effective for the treatment of chronic lymphocytic leukemia (CLL) and other B-cell lymphomas. Covalent BTK inhibitors (BTKis) led to an unprecedented improvement in outcome in CLL, in particular for high-risk subgroups with TP53 aberration and unmutated immunoglobulin heavy-chain variable-region gene (IGHV). Ibrutinib and acalabrutinib are approved by the US Food and Drug Administration for the treatment of CLL and other B-cell lymphomas, and zanubrutinib, for patients with mantle cell lymphoma. Distinct target selectivity of individual BTKis confer differences in target-mediated as well as off-target adverse effects. Disease progression on covalent BTKis, driven by histologic transformation or selective expansion of BTK and PLCG2 mutated CLL clones, remains a major challenge in the field. Fixed duration combination regimens and reversible BTKis with non-covalent binding chemistry hold promise for the prevention and treatment of BTKi-resistant disease.
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Affiliation(s)
- Inhye E Ahn
- Lymphoid Malignancies Section, National Heart, Lung, and Blood Institute, Bethesda, MD, United States
| | - Jennifer R Brown
- Chronic Lymphocytic Leukemia Center, Division of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, United States
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Frontline Treatment for Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL): Targeted Therapy vs. Chemoimmunotherapy. Curr Hematol Malig Rep 2021; 16:325-335. [PMID: 34021874 DOI: 10.1007/s11899-021-00637-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The treatment options for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) have expanded significantly in the last few years, including the use of new classes of oral small molecular inhibitors targeting the B cell receptor signaling pathway or the apoptosis machinery. Targeted therapy with or without immunotherapy has quickly emerged as a new standard for frontline treatment of CLL/SLL, though the previous standard chemoimmunotherapy (CIT) remains a treatment option. In this review, we present data from key clinical trials to evaluate the benefits and risks associated with different frontline treatment approaches. RECENT FINDINGS We reviewed recently published and presented clinical trials on frontline CLL/SLL treatment, with particular focus on the comparison of CIT vs. targeted therapies, including inhibitors of Bruton's tyrosine kinase (BTK) or of the anti-apoptotic protein Bcl-2. Various BTK inhibitors as continuous treatment with or without anti-CD20 monoclonal antibodies have compared favorably to the conventional CITs in previously untreated CLL/SLL patients of various ages and comorbidities. Fixed duration treatment with the Bcl-2 inhibitor venetoclax combined with anti-CD20 monoclonal antibodies also showed superiority in clinical outcomes compared to CIT. Subgroup analysis interestingly showed that IgHV-mutated CLL/SLL might still derive similar benefits from CIT. Ongoing clinical trials are investigating combined targeted therapies of venetoclax plus a BTK inhibitor to try to further improve the efficacy while limiting the duration of treatment. Targeted therapies are becoming the new standard of care for frontline treatment of CLL/SLL although conventional CIT remains an option group of fit patients with low risk features. Novel strategies are being studied using targeted therapy combinations to optimize the depth of response in a time-limited fashion.
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Al-Sawaf O, Seymour JF, Kater AP, Fischer K. Should Undetectable Minimal Residual Disease Be the Goal of Chronic Lymphocytic Leukemia Therapy? Hematol Oncol Clin North Am 2021; 35:775-791. [PMID: 34102145 DOI: 10.1016/j.hoc.2021.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With the advent of highly effective novel therapies for chronic lymphocytic leukemia, conventional response assessment is not able to sensitively capture depth of response. To achieve a more precise assessment of response, minimal residual disease has been introduced to more accurately classify and quantify treatment outcomes. It is now considered a strong predictor of outcome in chronic lymphocytic leukemia, although its interpretation depends on the therapeutic context. This review discusses available methods of minimal residual disease measurement. It summarizes minimal residual disease data from pivotal clinical trials and discusses potential implications for future studies and minimal residual disease-based clinical strategies.
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Affiliation(s)
- Othman Al-Sawaf
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
| | - John F Seymour
- Department of Hematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Research Center Amsterdam (LYMMCARE), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Kirsten Fischer
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
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Pneumocystis jirovecii pneumonia and institutional prophylaxis practices in CLL patients treated with BTK inhibitors. Blood Adv 2021; 4:1458-1463. [PMID: 32282880 DOI: 10.1182/bloodadvances.2020001678] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/06/2023] Open
Abstract
Opportunistic infections (OIs), such as Pneumocystis jirovecii pneumonia (PJP), have been reported in chronic lymphocytic leukemia (CLL) patients treated with ibrutinib, and are an important cause of morbidity and mortality. Currently, there are no international consensus guidelines regarding the use of antimicrobial prophylaxis for OIs, and in particular PJP, in CLL patients treated with Bruton tyrosine kinase inhibitors (BTKi's). We evaluated the frequency of PJP in CLL patients at our institution who were treated with BTKi's, and assessed the impact of prophylaxis on reducing the risk of PJP. We identified 217 patients treated with BTKi's, consisting of 3 cohorts: 143 patients on either BTKi monotherapy with ibrutinib or acalabrutinib, 17 patients receiving ibrutinib combination therapy with umbralisib as part of a clinical trial, and 57 patients receiving ibrutinib in combination with standard chemotherapy, also as part of a clinical trial. Forty-one percent of patients on BTKi monotherapy received prophylaxis, which was given at the discretion of the treating physician. The prevalence of PJP in all patients not on prophylaxis was 3.4% (3 of 87), and, specifically in BTKi-monotherapy patients not on prophylaxis, the PJP prevalence was 2.4% (2 of 85). PJP prophylaxis was effective, as there were no cases of PJP in patients on prophylaxis (0 of 130). The relatively low prevalence of PJP in our study population suggests that routine prophylaxis may not be indicated in CLL patients on BTKi therapy.
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Pérez-Carretero C, González-Gascón-y-Marín I, Rodríguez-Vicente AE, Quijada-Álamo M, Hernández-Rivas JÁ, Hernández-Sánchez M, Hernández-Rivas JM. The Evolving Landscape of Chronic Lymphocytic Leukemia on Diagnosis, Prognosis and Treatment. Diagnostics (Basel) 2021; 11:diagnostics11050853. [PMID: 34068813 PMCID: PMC8151186 DOI: 10.3390/diagnostics11050853] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/25/2021] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
The knowledge of chronic lymphocytic leukemia (CLL) has progressively deepened during the last forty years. Research activities and clinical studies have been remarkably fruitful in novel findings elucidating multiple aspects of the pathogenesis of the disease, improving CLL diagnosis, prognosis and treatment. Whereas the diagnostic criteria for CLL have not substantially changed over time, prognostication has experienced an expansion with the identification of new biological and genetic biomarkers. Thanks to next-generation sequencing (NGS), an unprecedented number of gene mutations were identified with potential prognostic and predictive value in the 2010s, although significant work on their validation is still required before they can be used in a routine clinical setting. In terms of treatment, there has been an impressive explosion of new approaches based on targeted therapies for CLL patients during the last decade. In this current chemotherapy-free era, BCR and BCL2 inhibitors have changed the management of CLL patients and clearly improved their prognosis and quality of life. In this review, we provide an overview of these novel advances, as well as point out questions that should be further addressed to continue improving the outcomes of patients.
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Affiliation(s)
- Claudia Pérez-Carretero
- Cancer Research Center (IBMCC) CSIC-University of Salamanca, 37007 Salamanca, Spain; (C.P.-C.); (A.E.R.-V.); (M.Q.-Á.)
- Instituto de Investigación Biomédica (IBSAL), 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | | | - Ana E. Rodríguez-Vicente
- Cancer Research Center (IBMCC) CSIC-University of Salamanca, 37007 Salamanca, Spain; (C.P.-C.); (A.E.R.-V.); (M.Q.-Á.)
- Instituto de Investigación Biomédica (IBSAL), 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - Miguel Quijada-Álamo
- Cancer Research Center (IBMCC) CSIC-University of Salamanca, 37007 Salamanca, Spain; (C.P.-C.); (A.E.R.-V.); (M.Q.-Á.)
- Instituto de Investigación Biomédica (IBSAL), 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - José-Ángel Hernández-Rivas
- Department of Hematology, Infanta Leonor University Hospital, 28031 Madrid, Spain; (I.G.-G.-y-M.); (J.-Á.H.-R.)
- Department of Medicine, Complutense University, 28040 Madrid, Spain
| | - María Hernández-Sánchez
- Cancer Research Center (IBMCC) CSIC-University of Salamanca, 37007 Salamanca, Spain; (C.P.-C.); (A.E.R.-V.); (M.Q.-Á.)
- Instituto de Investigación Biomédica (IBSAL), 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
- Correspondence: (M.H.-S.); (J.M.H.-R.); Tel.: +34-923-294-812 (M.H.-S. & J.M.H.-R.)
| | - Jesús María Hernández-Rivas
- Cancer Research Center (IBMCC) CSIC-University of Salamanca, 37007 Salamanca, Spain; (C.P.-C.); (A.E.R.-V.); (M.Q.-Á.)
- Instituto de Investigación Biomédica (IBSAL), 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
- Department of Medicine, University of Salamanca, 37008 Salamanca, Spain
- Correspondence: (M.H.-S.); (J.M.H.-R.); Tel.: +34-923-294-812 (M.H.-S. & J.M.H.-R.)
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Timofeeva N, Gandhi V. Ibrutinib combinations in CLL therapy: scientific rationale and clinical results. Blood Cancer J 2021; 11:79. [PMID: 33927183 PMCID: PMC8085243 DOI: 10.1038/s41408-021-00467-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/15/2021] [Accepted: 03/26/2021] [Indexed: 12/13/2022] Open
Abstract
Ibrutinib has revolutionized the treatment of chronic lymphocytic leukemia (CLL). This drug irreversibly inhibits Bruton tyrosine kinase (BTK) by covalently binding to the C481 residue in the BTK kinase domain. BTK is a pivotal protein for B cell receptor signaling and tissue homing of CLL cells. Preclinical investigations have established the importance of the B cell receptor pathway in the maintenance and survival of normal and malignant B cells, underscoring the importance of targeting this axis for CLL. Clinical trials demonstrated overall and progression-free survival benefit with ibrutinib in multiple CLL subgroups, including patients with relapsed or refractory disease, patients with 17p deletion, elderly patients, and treatment-naïve patients. Consequently, ibrutinib was approved by the US Food and Drug Administration for newly diagnosed and relapsed disease. Ibrutinib has transformed the treatment of CLL; however, several limitations have been identified, including low complete remission rates, development of resistance, and uncommon substantial toxicities. Further, ibrutinib must be used until disease progression, which imposes a financial burden on patients and society. These limitations were the impetus for the development of ibrutinib combinations. Four strategies have been tested in recent years: combinations of ibrutinib with immunotherapy, chemoimmunotherapy, cell therapy, and other targeted therapy. Here, we review the scientific rationale for and clinical outcome of each strategy. Among these strategies, ibrutinib with targeted agent venetoclax results in high complete response rates and, importantly, high rates of undetectable minimal residual disease. Although we concentrate here on ibrutinib, similar combinations are expected or ongoing with acalabrutinib, tirabrutinib, and zanubrutinib, second-generation BTK inhibitors. Future investigations will focus on the feasibility of discontinuing ibrutinib combinations after a defined time; the therapeutic benefit of adding a third agent to ibrutinib-containing combinations; and profiling of resistant clones that develop after combination treatment. A new standard of care for CLL is expected to emerge from these investigations.
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Affiliation(s)
- Natalia Timofeeva
- Departments of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Varsha Gandhi
- Departments of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
- Departments of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA.
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Gu D, Tang H, Wu J, Li J, Miao Y. Targeting Bruton tyrosine kinase using non-covalent inhibitors in B cell malignancies. J Hematol Oncol 2021; 14:40. [PMID: 33676527 PMCID: PMC7937220 DOI: 10.1186/s13045-021-01049-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/18/2021] [Indexed: 12/14/2022] Open
Abstract
B cell receptor (BCR) signaling is involved in the pathogenesis of B cell malignancies. Activation of BCR signaling promotes the survival and proliferation of malignant B cells. Bruton tyrosine kinase (BTK) is a key component of BCR signaling, establishing BTK as an important therapeutic target. Several covalent BTK inhibitors have shown remarkable efficacy in the treatment of B cell malignancies, especially chronic lymphocytic leukemia. However, acquired resistance to covalent BTK inhibitors is not rare in B cell malignancies. A major mechanism for the acquired resistance is the emergence of BTK cysteine 481 (C481) mutations, which disrupt the binding of covalent BTK inhibitors. Additionally, adverse events due to the off-target inhibition of kinases other than BTK by covalent inhibitors are common. Alternative therapeutic options are needed if acquired resistance or intolerable adverse events occur. Non-covalent BTK inhibitors do not bind to C481, therefore providing a potentially effective option to patients with B cell malignancies, including those who have developed resistance to covalent BTK inhibitors. Preliminary clinical studies have suggested that non-covalent BTK inhibitors are effective and well-tolerated. In this review, we discussed the rationale for the use of non-covalent BTK inhibitors and the preclinical and clinical studies of non-covalent BTK inhibitors in B cell malignancies.
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Affiliation(s)
- Danling Gu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China
- Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Hanning Tang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China
- Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Jiazhu Wu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China
- Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.
- Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China.
- Pukou CLL Center, Nanjing, 210000, China.
| | - Yi Miao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.
- Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China.
- Pukou CLL Center, Nanjing, 210000, China.
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Bose P, Gandhi V. Managing chronic lymphocytic leukemia in 2020: an update on recent clinical advances with a focus on BTK and BCL-2 inhibitors. Fac Rev 2021; 10:22. [PMID: 33718939 PMCID: PMC7946394 DOI: 10.12703/r/10-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The therapeutic landscape of chronic lymphocytic leukemia (CLL) underwent a paradigm shift in 2014 with the approval of ibrutinib, which binds covalently to the C481 residue of Bruton's tyrosine kinase (BTK) and irreversibly inhibits it. A number of large, phase 3 trials conducted in both the frontline and the relapsed/refractory settings resulted in the approval of ibrutinib for all CLL. Indeed, the role of chemoimmunotherapy in CLL is fast dwindling. The limitations of ibrutinib, e.g. the development of resistance-conferring C481 BTK mutations and the toxicity issues of atrial fibrillation and bleeding, in particular, have also become apparent with longer-term follow-up. This has spurred the development of second-generation, irreversible inhibitors with greater selectivity for BTK and third-generation, reversible BTK inhibitors to address C481 site mutations. The last 3 years have also witnessed enormous growth in the therapeutic role of the B-cell lymphoma 2 (BCL-2) antagonist venetoclax, initially approved (in 2016) only for patients with relapsed, 17p-deleted CLL. Venetoclax, in combination with CD20 antibodies, is currently approved for both treatment-naïve and relapsed/refractory patients, regardless of genomic subtype. Robust results have also been reported for ibrutinib plus venetoclax, and "triple" combinations of a BTK inhibitor, venetoclax, and obinutuzumab are now being pursued. The major questions facing the field at present are how best to select patients for BTK inhibitor monotherapy versus venetoclax/obinutuzumab upfront, what to do after failure of both BTK inhibitor(s) and venetoclax, and the ideal way to integrate measurable residual disease data into decisions regarding treatment choice, duration, and discontinuation.
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Affiliation(s)
- Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Varsha Gandhi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Tempero M, Oh DY, Tabernero J, Reni M, Van Cutsem E, Hendifar A, Waldschmidt DT, Starling N, Bachet JB, Chang HM, Maurel J, Garcia-Carbonero R, Lonardi S, Coussens LM, Fong L, Tsao LC, Cole G, James D, Macarulla T. Ibrutinib in combination with nab-paclitaxel and gemcitabine for first-line treatment of patients with metastatic pancreatic adenocarcinoma: phase III RESOLVE study. Ann Oncol 2021; 32:600-608. [PMID: 33539945 DOI: 10.1016/j.annonc.2021.01.070] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/16/2021] [Accepted: 01/20/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND First-line treatment of metastatic pancreatic ductal adenocarcinoma (PDAC) includes nab-paclitaxel/gemcitabine. Ibrutinib, a Bruton's tyrosine kinase inhibitor, exhibits antitumor activity through tumor microenvironment modulation. The safety and efficacy of first-line ibrutinib plus nab-paclitaxel/gemcitabine treatment in patients with PDAC were evaluated. PATIENTS AND METHODS RESOLVE (NCT02436668) was a phase III, randomized, double-blind, placebo-controlled study. Patients (histologically-confirmed PDAC; stage IV diagnosis ≥6 weeks of randomization; Karnofsky performance score ≥70) were randomized to once-daily oral ibrutinib (560 mg) or placebo plus nab-paclitaxel (125 mg/m2) and gemcitabine (1000 mg/m2). Primary endpoints were overall survival (OS) and investigator-assessed progression-free survival (PFS); overall response rate and safety were assessed. RESULTS In total, 424 patients were randomized (ibrutinib arm, n = 211; placebo arm, n = 213). Baseline characteristics were balanced across arms. After a median follow-up of 25 months, there was no significant difference in OS between ibrutinib plus nab-paclitaxel/gemcitabine versus placebo plus nab-paclitaxel/gemcitabine (median of 9.7 versus 10.8 months; P = 0.3225). PFS was shorter for ibrutinib plus nab-paclitaxel/gemcitabine compared with placebo plus nab-paclitaxel/gemcitabine (median 5.3 versus 6.0 months; P < 0.0001). Overall response rates were 29% and 42%, respectively (P = 0.0058). Patients in the ibrutinib arm had less time on treatment and received lower cumulative doses for all agents compared with the placebo arm. The most common grade ≥3 adverse events for ibrutinib versus placebo arms included neutropenia (24% versus 35%), peripheral sensory neuropathy (17% versus 8%), and anemia (16% versus 17%). Primary reasons for any treatment discontinuation were disease progression and adverse events. CONCLUSIONS Ibrutinib plus nab-paclitaxel/gemcitabine did not improve OS or PFS for patients with PDAC. Safety was consistent with known profiles for these agents.
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Affiliation(s)
- M Tempero
- Department of Medicine, University of California San Francisco, San Francisco, USA.
| | - D-Y Oh
- Department of Internal Medicine, Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - J Tabernero
- Department of Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), IOB-Quiron, UVic-UICC, CIBERONC, Barcelona, Spain
| | - M Reni
- Department of Radiochemotherapy, San Raffaele Hospital Scientific Institute, Milan, Italy
| | - E Van Cutsem
- Department of Digestive Oncology, University Hospitals Gasthuisberg/Leuven & KU Leuven, Leuven, Belgium
| | - A Hendifar
- Department of Medical Oncology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - D-T Waldschmidt
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - N Starling
- Section of GI and Lymphoma Units, Department of Medicine, The Royal Marsden, London, UK
| | - J-B Bachet
- Department of Hepatogastroenterology, UPMC, Sorbonne University, Pitié Salpêtrière Hospital, APHP, Paris, France
| | - H-M Chang
- Division of Oncology, Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, South Korea
| | - J Maurel
- Department of Medical Oncology, Translational Genomics and Targeted Therapeutics in Solid Tumors Group, IDIBAPS, Hospital Clinic Barcelona, University of Barcelona, Barcelona, Spain
| | - R Garcia-Carbonero
- Department of Medical Oncology, Hospital Universitario Doce de Octubre, Imas12, UCM, CNIO, CIBERONC, Madrid, Spain
| | - S Lonardi
- Dipartimento di Oncologia Clinical e Sperimentale, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - L M Coussens
- Department of Cell, Developmental & Cancer Biology, Knight Cancer Institute, Oregon Health & Science University, Portland, USA
| | - L Fong
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - L C Tsao
- Department of Statistics, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, USA
| | - G Cole
- Department of Oncology Development, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, USA
| | - D James
- Department of Clinical Science, Pharmacyclics LLC, an AbbVie Company, Sunnyvale, USA
| | - T Macarulla
- Department of Medical Oncology, Vall d'Hebron University Hospital and Institute of Oncology (VHIO), IOB-Quiron, UVic-UICC, CIBERONC, Barcelona, Spain
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Gordon MJ, Danilov AV. The evolving role of Bruton's tyrosine kinase inhibitors in chronic lymphocytic leukemia. Ther Adv Hematol 2021; 12:2040620721989588. [PMID: 33796237 PMCID: PMC7970705 DOI: 10.1177/2040620721989588] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 01/04/2021] [Indexed: 12/31/2022] Open
Abstract
Ibrutinib, the first in class of the oral covalent Bruton tyrosine kinase (BTK) inhibitors, has profoundly changed the treatment landscape of chronic lymphocytic leukemia (CLL). The phase III RESONATE and RESONATE-2 trials first demonstrated the superiority of ibrutinib over ofatumumab in the relapsed/refractory setting and over chlorambucil in older patients with de novo disease. The phase III ECOG–ACRIN trial extended these results to young, fit patients, demonstrating a significant survival advantage to ibrutinib plus rituximab over fludarabine, cyclophosphamide, and rituximab. Similarly, the Alliance trial demonstrated the superiority of ibrutinib over bendamustine with rituximab as frontline in elderly patients. Challenges with ibrutinib include toxicity, development of resistance, and need for indefinite therapy. The second generation BTK inhibitor acalabrutinib may cause less off-target toxicity. The ELEVATE TN trial demonstrated the superiority of acalabrutinib with or without obinutuzumab over chlorambucil and obinutuzumab as frontline therapy for elderly or comorbid patients. Promising early results from the phase II CAPTIVATE and CLARITY trials, which combined ibrutinib with venetoclax, suggest a future role for minimal residual disease (MRD) testing to determine treatment duration. The ongoing phase III GAIA/CLL13, ECOG EA9161, Alliance A041702, CLL17, and [ClinicalTrials.gov identifier: NCT03836261] trials will assess various combinations of ibrutinib/acalabrutinib, venetoclax, and anti-CD20 antibodies. These trials will answer key questions in the treatment of CLL: should novel agents in CLL be used in combination or sequentially? What is the best frontline agent? Can treatment be safely stopped with BTK inhibitors? Can undetectable MRD be used to determine treatment duration? In this review, we will discuss these and other aspects of the evolving role of BTK inhibition in CLL.
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Affiliation(s)
- Max J Gordon
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Alexey V Danilov
- City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010, USA
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Chong SJF, Iskandar K, Lai JXH, Qu J, Raman D, Valentin R, Herbaux C, Collins M, Low ICC, Loh T, Davids M, Pervaiz S. Serine-70 phosphorylated Bcl-2 prevents oxidative stress-induced DNA damage by modulating the mitochondrial redox metabolism. Nucleic Acids Res 2021; 48:12727-12745. [PMID: 33245769 PMCID: PMC7736805 DOI: 10.1093/nar/gkaa1110] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/25/2020] [Accepted: 10/29/2020] [Indexed: 12/16/2022] Open
Abstract
Bcl-2 phosphorylation at serine-70 (S70pBcl2) confers resistance against drug-induced apoptosis. Nevertheless, its specific mechanism in driving drug-resistance remains unclear. We present evidence that S70pBcl2 promotes cancer cell survival by acting as a redox sensor and modulator to prevent oxidative stress-induced DNA damage and execution. Increased S70pBcl2 levels are inversely correlated with DNA damage in chronic lymphocytic leukemia (CLL) and lymphoma patient-derived primary cells as well as in reactive oxygen species (ROS)- or chemotherapeutic drug-treated cell lines. Bioinformatic analyses suggest that S70pBcl2 is associated with lower median overall survival in lymphoma patients. Empirically, sustained expression of the redox-sensitive S70pBcl2 prevents oxidative stress-induced DNA damage and cell death by suppressing mitochondrial ROS production. Using cell lines and lymphoma primary cells, we further demonstrate that S70pBcl2 reduces the interaction of Bcl-2 with the mitochondrial complex-IV subunit-5A, thereby reducing mitochondrial complex-IV activity, respiration and ROS production. Notably, targeting S70pBcl2 with the phosphatase activator, FTY720, is accompanied by an enhanced drug-induced DNA damage and cell death in CLL primary cells. Collectively, we provide a novel facet of the anti-apoptotic Bcl-2 by demonstrating that its phosphorylation at serine-70 functions as a redox sensor to prevent drug-induced oxidative stress-mediated DNA damage and execution with potential therapeutic implications.
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Affiliation(s)
- Stephen Jun Fei Chong
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kartini Iskandar
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Jolin Xiao Hui Lai
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Jianhua Qu
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Deepika Raman
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Rebecca Valentin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Charles Herbaux
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary Collins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ivan Cherh Chiet Low
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | - Thomas Loh
- Department of Otolaryngology, National University of Healthcare System (NUHS), Singapore, Singapore
| | - Matthew Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Shazib Pervaiz
- Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore.,NUS Graduate School of Integrative Science and Engineering, NUS, Singapore, Singapore.,National University Cancer Institute, NUHS, Singapore, Singapore.,Faculté de Médecine, Université de Paris, Paris, France
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41
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Lee JC, Lamanna N. Is There a Role for Chemotherapy in the Era of Targeted Therapies? Curr Hematol Malig Rep 2020; 15:72-82. [PMID: 32107713 DOI: 10.1007/s11899-020-00563-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The treatment landscape of chronic lymphocytic leukemia has been rapidly evolving over the past few years. The prior standard of care, chemoimmunotherapy, is being replaced by targeted agents, and the utility of chemotherapy has come under question. In this review, we examine recent data comparing chemoimmunotherapy to targeted agents, how these data impact clinical management, and whether there are potential future roles for cytotoxic chemotherapy. RECENT FINDINGS Clinical trials have shown improved clinical outcomes with targeted agents compared to traditional chemoimmunotherapy. Based on these data, the current treatment paradigm primarily favors targeted agents over chemoimmunotherapy, with a few exceptions. However, targeted agents have notable limitations, and thus, there may be a future role of cytotoxic chemotherapy when administered in combination with targeted agents. Although targeted agents have nearly replaced chemoimmunotherapy in the treatment of chronic lymphocytic leukemia, novel combinations utilizing chemotherapy are being developed that may lead to better outcomes.
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Affiliation(s)
| | - Nicole Lamanna
- Columbia University Medical Center, NY, USA. .,Associate Attending, Leukemia Service, Director of the Chronic Lymphocytic Leukemia Program, Hematologic Malignancies Section, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian/Columbia University Medical Center, NY, USA.
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42
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Inhibitors targeting Bruton's tyrosine kinase in cancers: drug development advances. Leukemia 2020; 35:312-332. [PMID: 33122850 PMCID: PMC7862069 DOI: 10.1038/s41375-020-01072-6] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/27/2020] [Accepted: 10/15/2020] [Indexed: 12/16/2022]
Abstract
Bruton’s tyrosine kinase (BTK) inhibitor is a promising novel agent that has potential efficiency in B-cell malignancies. It took approximately 20 years from target discovery to new drug approval. The first-in-class drug ibrutinib creates possibilities for an era of chemotherapy-free management of B-cell malignancies, and it is so popular that gross sales have rapidly grown to more than 230 billion dollars in just 6 years, with annual sales exceeding 80 billion dollars; it also became one of the five top-selling medicines in the world. Numerous clinical trials of BTK inhibitors in cancers were initiated in the last decade, and ~73 trials were intensively announced or updated with extended follow-up data in the most recent 3 years. In this review, we summarized the significant milestones in the preclinical discovery and clinical development of BTK inhibitors to better understand the clinical and commercial potential as well as the directions being taken. Furthermore, it also contributes impactful lessons regarding the discovery and development of other novel therapies.
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Xue C, Wang X, Zhang L, Qu Q, Zhang Q, Jiang Y. Ibrutinib in B-cell lymphoma: single fighter might be enough? Cancer Cell Int 2020; 20:467. [PMID: 33005100 PMCID: PMC7523373 DOI: 10.1186/s12935-020-01518-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022] Open
Abstract
Background In recent years, the B cell receptor (BCR) signaling pathway has become a "hot point" because it plays a critical role in B-cell proliferation and function. Bruton's tyrosine kinase (BTK) is overexpressed in many subtypes of B-cell lymphoma as a downstream kinase in the BCR signaling pathway. Ibrutinib, the first generation of BTK inhibitor, has shown excellent antitumor activity in both indolent and aggressive B-cell lymphoma. Main body Ibrutinib monotherapy has been confirmed to be effective with a high response rate (RR) and well-tolerated in many B-cell lymphoma subgroups. To achieve much deeper and faster remission, combination strategies contained ibrutinib were conducted to evaluate their synergistic anti-tumor effect. Conclusions For patients with indolent B-cell lymphoma, most of them respond well with ibrutinib monotherapy. Combination strategies contained ibrutinib might be a better choice to achieve deeper and faster remission in the treatment of aggressive subtypes of B-cell lymphoma. Further investigations on the long-term efficacy and safety of the ibrutinib will provide novel strategies for individualized treatment of B-cell lymphoma.
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Affiliation(s)
- Chao Xue
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 China.,School of Medicine, Shandong University, Jinan, 250012 Shandong China.,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, 250021 Jinan, Shandong China
| | - Lingyan Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, 250021 Jinan, Shandong China
| | - Qingyuan Qu
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 China
| | - Qian Zhang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, 250021 Jinan, Shandong China
| | - Yujie Jiang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, 250021 Jinan, Shandong China
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Prognostic value of high-sensitivity measurable residual disease assessment after front-line chemoimmunotherapy in chronic lymphocytic leukemia. Leukemia 2020; 35:1597-1609. [PMID: 32934355 DOI: 10.1038/s41375-020-01009-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 12/21/2022]
Abstract
Measurable residual disease (MRD) status is widely adopted in clinical trials in patients with chronic lymphocytic leukemia (CLL). Findings from FILO group trials (CLL2007FMP, CLL2007SA, CLL2010FMP) enabled investigation of the prognostic value of high-sensitivity (0.7 × 10-5) MRD assessment using flow cytometry, in blood (N = 401) and bone marrow (N = 339), after fludarabine, cyclophosphamide, and rituximab (FCR)-based chemoimmunotherapy in a homogeneous population with long follow-up (median 49.5 months). Addition of low-level positive MRD < 0.01% to MRD ≥ 0.01% increased the proportion of cases with positive MRD in blood by 39% and in bone marrow by 27%. Compared to low-level positive MRD < 0.01%, undetectable MRD was associated with significantly longer progression-free survival (PFS) when using blood (72.2 versus 42.7 months; hazard ratio 0.40, p = 0.0003), but not when using bone marrow. Upon further stratification, positive blood MRD at any level, compared to undetectable blood MRD, was associated with shorter PFS irrespective of clinical complete or partial remission, and a lower 5-year PFS rate irrespective of IGHV-mutated or -unmutated status (all p < 0.05). In conclusion, high-sensitivity (0.0007%) MRD assessment in blood yielded additional prognostic information beyond the current standard sensitivity (0.01%). Our approach provides a model for future determination of the optimal MRD investigative strategy for any regimen.
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Thompson P. BTK Inhibitors and Chemoimmunotherapy for CLL. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20 Suppl 1:S22-S24. [PMID: 32862855 DOI: 10.1016/s2152-2650(20)30449-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, Texas, 77030, United States.
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Davids MS, Fisher DC, Tyekucheva S, McDonough M, Hanna J, Lee B, Francoeur K, Montegaard J, Odejide O, Armand P, Arnason J, Brown JR. A phase 1b/2 study of duvelisib in combination with FCR (DFCR) for frontline therapy for younger CLL patients. Leukemia 2020; 35:1064-1072. [PMID: 32820271 PMCID: PMC7895867 DOI: 10.1038/s41375-020-01010-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023]
Abstract
Fludarabine, cyclophosphamide, and rituximab (FCR) is highly effective initial therapy for younger patients with chronic lymphocytic leukemia (CLL); however, most eventually relapse. Duvelisib is a delta/gamma PI3K inhibitor approved for relapsed/refractory CLL. We conducted an investigator-initiated, phase 1b/2 study of duvelisib + FCR (DFCR) as initial treatment for CLL patients aged ≤65. A standard 3 + 3 design included two dose levels of duvelisib (25 mg qd and 25 mg bid). Duvelisib was given for 1 week, then with standard FCR added for up to six 28-day cycles, then up to 2 years of duvelisib maintenance. Thirty-two patients were enrolled. The phase 2 dose of duvelisib was identified as 25 mg bid. Hematologic toxicity was common, and all-grade non-hematologic toxicities included transaminitis (28%), febrile neutropenia (22%), pneumonia (19%), and colitis (6%). The best overall response rate by ITT was 88% (56% CR/CRi and 32% PR). The best rate of bone marrow undetectable minimal residual disease (BM-uMRD) by ITT was 66%. The rate of CR with BM-uMRD at end of combination treatment (primary endpoint) was 25%. Three-year PFS and OS are 73 and 93%, respectively. DFCR is active as initial therapy of younger CLL patients. Immune-mediated and infectious toxicities occurred and required active management.
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Affiliation(s)
- Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Svitlana Tyekucheva
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mikaela McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandon Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karen Francoeur
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Oreofe Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jon Arnason
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Abstract
The evaluation of minimal residual disease (MRD) in chronic lymphocytic leukemia (CLL) has evolved in parallel with the enormous progresses in the therapeutic armamentarium and the application of cutting-edge diagnostic techniques the CLL community witnessed in the past few years. Minimal residual disease is considered an objective measure of disease status defined by the number of residual leukemic cells detected in a sample of peripheral blood and/or bone marrow as proportion of the total white blood cells and defined undetectable if fewer than 1 CLL cell among 10,000 white blood cells (10 or 0.01%) is detected. In this review, we aim at shedding light on how to evaluate MRD, what we already know about MRD from the experience with chemoimmunotherapy, and why MRD evaluation remains still relevant in the era of targeted agents.
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MESH Headings
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/history
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Drug Resistance, Neoplasm
- Female
- History, 20th Century
- History, 21st Century
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Mutation
- Prognosis
- Receptors, Antigen, B-Cell/genetics
- Receptors, Antigen, B-Cell/metabolism
- Signal Transduction
- Survival Rate
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Affiliation(s)
- Jan A Burger
- From the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston
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Shadman M, Stephens DM. Debate: What Is Optimal First-Line Therapy for Chronic Lymphocytic Leukemia? J Natl Compr Canc Netw 2020. [DOI: 10.6004/jnccn.2020.5011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In the era of newer, highly effective targeted therapies for chronic lymphocytic leukemia (CLL), experts debated whether there is still a role for chemoimmunotherapy in the first-line setting for the treatment of this disease. In general, targeted therapies are preferred as first-line treatment for all patients, with the exception of low-risk patients [younger, fit patients with mutated IGHV who are candidates for fludarabine/cyclophosphamide/rituximab (FCR)]. About 37% of low-risk patients experience long-term durable remissions and remain stable after treatment with FCR for many years. Advantages of FCR over small molecule inhibitors include cost, fixed duration treatment, and long-term survival benefit. Disadvantages are an etimated 5% risk of developing myelodysplastic syndrome or acute myeloid leukemia. Advantages of small molecule inhibitors are improvements in progression-free and overall survival and quality of life when compared with chemoimmunotherapy. Disadvantages of small molecule inhibitors are high cost and the need for continuous treatment. However, studies are underway to develop fixed duration regimens with combinations of small molecule inhibitors that aim to deepen remissions.
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Iskierka-Jażdżewska E, Robak T. Investigational treatments for chronic lymphocytic leukemia: a focus on phase 1 and 2 clinical trials. Expert Opin Investig Drugs 2020; 29:709-722. [PMID: 32407139 DOI: 10.1080/13543784.2020.1770225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: During recent years, the introduction of novel drugs, particularly small molecule inhibitors, has led to remarkable progress in both previously untreated and relapsed/refractory (RR) patients in chronic lymphocytic leukemia (CLL). However, further research is necessary to find an optimal cure that responds to the individual needs of the patient. Areas covered: This review discusses new agents in phase 1 and 2 clinical trials currently underway in CLL patients. A literature review of the MEDLINE database for articles in English concerning novel drugs, clinical trials, phase 1, phase 2 and CLL was conducted via PubMed. Publications from 2000 through January 2020 were scrutinized. Conference proceedings from the previous five years of the American Society of Hematology, European Hematology Association and American Society of Clinical Oncology were searched manually. Additional relevant publications were obtained by reviewing the references from the chosen articles. The search also included clinical trials registered in clinicaltrials.gov. Expert opinion: The use of BTK and PI3Kδ inhibitors and BCL-2 antagonist have changed the treatment strategy of CLL. Several clinical trials with novel, unapproved agents are currently ongoing. Their findings should define the role of these novel drugs in the treatment of patients with previously untreated and RR CLL.
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Affiliation(s)
| | - Tadeusz Robak
- Department of Hematology, Copernicus Memorial Hospital, Lodz, Medical University of Lodz , Lodz, Poland
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