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Tam CS. Upfront therapy: the case for continuous treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:55-58. [PMID: 34889433 PMCID: PMC8791150 DOI: 10.1182/hematology.2021000232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Both BTKi and BCL2i are regarded as standards of care for frontline treatment of CLL. In this paper, I present the arguments for favoring BTKi as initial therapy. Venetoclax-based regimens have the advantage of being fixed in duration, but patients with select high-risk features may experience inferior PFS relative to those without high-risk features.
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Affiliation(s)
- Constantine S. Tam
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia; and The Royal Melbourne Hospital, Parkville, Victoria, Australia
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2
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Aitken MJL, Lee HJ, Post SM. Emerging treatment options for patients with p53-pathway-deficient CLL. Ther Adv Hematol 2019; 10:2040620719891356. [PMID: 31839919 PMCID: PMC6896129 DOI: 10.1177/2040620719891356] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 11/06/2019] [Indexed: 11/17/2022] Open
Abstract
Over the past 40 years, p53 has been the most widely studied protein in cancer biology. Originally thought to be an oncogene due to its stabilization in many cancers, it is now considered to be one of the most critical tumor suppressors in a cell's ability to combat neoplastic transformation. Due to its critical roles in apoptosis, cell-cycle arrest, and senescence, TP53 deletions and mutations are commonly observed and are often a portent of treatment failures and poor clinical outcomes. This is particularly true in chronic lymphocytic leukemia (CLL), as patients with p53 alterations have historically had dismal outcomes. As such, the tremendous efforts made to better understand the functions of p53 in CLL have contributed substantially to recent advances in treating patients with p53-pathway-deficient CLL.
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Affiliation(s)
- Marisa J L Aitken
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hun J Lee
- Department of Lymphoma and Multiple Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean M Post
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, Houston, TX 77030-4000, USA
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3
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Tam C, Seymour J. Choosing and sequencing novel drugs in CLL: dealing with an embarrassment of riches? Ann Oncol 2017; 28:920-921. [DOI: 10.1093/annonc/mdx103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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4
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Jacobs RW, Awan FT, Leslie LA, Usmani SZ, Ghosh N. The shrinking role of chemotherapy in the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:1177-1187. [DOI: 10.1080/17474086.2016.1254545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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5
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Park T, Griggs SK, Suh DC. Cost Effectiveness of Monoclonal Antibody Therapy for Rare Diseases: A Systematic Review. BioDrugs 2016; 29:259-74. [PMID: 26263903 DOI: 10.1007/s40259-015-0135-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Monoclonal antibody (mAb)-based orphan drugs have led to advances in the treatment of diseases by selectively targeting molecule functions. However, their high treatment costs impose a substantial cost burden on patients and society. OBJECTIVES The study aimed to systematically review cost-effectiveness evidence of mAb orphan drugs. METHODS Ovid MEDLINE(®), EMBASE(®), and PsycINFO(®) were searched in June 2014 and articles were selected if they conducted economic evaluations of the mAb orphan drugs that had received marketing approval in the USA. The quality of the selected studies was assessed using the Quality of Health Economic Studies (QHES) instrument. RESULTS We reviewed 16 articles that included 24 economic evaluations of nine mAb orphan drugs. Six of these nine drugs were included in cost-utility analysis studies, whereas three drugs were included in cost-effectiveness analysis studies. Previous cost-utility analysis studies revealed that four mAb orphan drugs (cetuximab, ipilimumab, rituximab, and trastuzumab) were found to be cost effective; one drug (bevacizumab) was not cost effective; and one drug (infliximab) was not consistent across the studies. Prior cost-effectiveness analysis studies which included three mAb orphan drugs (adalimumab, alemtuzumab, and basiliximab) showed that the incremental cost per effectiveness gained for these drugs ranged from $US4669 to $Can52,536 Canadian dollars. The quality of the included studies was good or fair with the exception of one study. CONCLUSIONS Some mAb orphan drugs were reported as cost effective under the current decision-making processes. Use of these expensive drugs, however, can raise an equity issue which concerns fairness in access to treatment. The issue of equal access to drugs needs to be considered alongside other societal values in making the final health policy decisions.
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Affiliation(s)
- Taehwan Park
- Pharmacy Administration, St. Louis College of Pharmacy, St. Louis, MO, USA
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6
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Chavez JC, Piris-Villaespesa M, Dalia S, Powers J, Turba E, Nodzon L, Komrokji R, Sokol L, Locke FL, Lancet J, Sotomayor EM, Kharfan-Dabaja MA, Pinilla-Ibarz J. Results of a phase II study of lenalidomide and rituximab for refractory/relapsed chronic lymphocytic leukemia. Leuk Res 2016; 47:78-83. [PMID: 27285853 DOI: 10.1016/j.leukres.2016.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/12/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is an incurable disease in need of new therapeutic strategies. The immunomodulatory agent, lenalidomide, has shown activity as salvage therapy for CLL. In this phase II trial, we combined lenalidomide with rituximab in 25 patients (range, 41-79) with refractory/relapsed CLL. Lenalidomide was administered orally on escalating doses, with cycle 1 doses of 2.5mg daily on days 1-7, 5mg on days 8-14, and 10mg on days 15-21 followed by 7days off. On cycle 2 and beyond, lenalidomide was administered at 20mg daily on days 1-21. Rituximab was administered at 375mg/m(2) intravenously on a weekly basis for the first cycle starting on day 15 for 4 doses, with each cycle being 28days. Treatment was continued until disease progression or toxicity. Overall response rate was 45.8% on intent-to-treat and 61.1% in evaluable patients (all partial responses). Median time to treatment failure was 14.3 months for evaluable patients, and median overall survival was not reached. The most common grade 3/4 toxicity was neutropenia (72% of patients). The most common nonhematologic toxicity was infection (29% of patients). Lenalidomide combined with rituximab showed activity in heavily treated refractory CLL with an acceptable toxicity profile.
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Affiliation(s)
- Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States.
| | | | - Samir Dalia
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - John Powers
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Elyce Turba
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Lisa Nodzon
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Rami Komrokji
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Lubomir Sokol
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Frederick L Locke
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Jeffrey Lancet
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | - Eduardo M Sotomayor
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
| | | | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, United States
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7
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Šimkovič M, Motyčková M, Belada D, Vodárek P, Kapoor R, Jaffar H, Vrbacký F, Žák P, Smolej L. Five years of experience with rituximab plus high-dose dexamethasone for relapsed/refractory chronic lymphocytic leukemia. Arch Med Sci 2016; 12:421-7. [PMID: 27186190 PMCID: PMC4848354 DOI: 10.5114/aoms.2016.55425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION High-dose methylprednisolone (HDMP) in combination with rituximab is active in the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL), but serious infections are frequent. Recently published data suggested that high-dose dexamethasone might be equally effective as HDMP despite a lower cumulative dose. MATERIAL AND METHODS We performed retrospective analysis of 60 patients with relapsed/refractory CLL (median age: 66 years; range: 37-86) treated with rituximab plus dexamethasone (R-dex) at a single tertiary center between September 2008 and October 2012. The schedule of R-dex consisted of rituximab 500 mg/m(2) i.v. day 1 (375 mg/m(2) in cycle 1) and dexamethasone 40 mg orally on days 1-4 and 10-13 repeated every 3 weeks for a maximum of 8 cycles. Unfavorable prognostic features were frequent (Rai stages III/IV in 67%, unmutated IgVH 82%, del 11q 43%, TP53 mutation/deletion 23%, bulky lymphadenopathy 58% of patients). RESULTS Overall response (OR)/complete remission (CR) was achieved in 75/3%. At the median follow-up of 21 months, median progression-free survival (PFS) was 8 months, median time to next treatment 12.9 months and median overall survival 25.5 months. Refractoriness to fludarabine (p = 0.04) and age ≥ 65 years (p = 0.03) were significant predictors of shorter PFS. R-dex was successfully used for debulking before allogenic stem cell transplantation in 7 patients (12%). Serious (CTCAE grade III/IV) infections occurred in 27% of patients; 20% of patients developed steroid diabetes requiring temporary short-acting insulin. CONCLUSIONS Our results show that R-dex is an active and well-tolerated regimen for patients with relapsed/refractory CLL; however, major infections remain frequent despite combined antimicrobial prophylaxis.
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Affiliation(s)
- Martin Šimkovič
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Monika Motyčková
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - David Belada
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Pavel Vodárek
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Rahul Kapoor
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Hamna Jaffar
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Filip Vrbacký
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Pavel Žák
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Lukáš Smolej
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
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Chang JE, Havighurst T, Kim K, Eickhoff J, Traynor AM, Kirby-Slimp R, Volk LM, Werndli J, Go RS, Weiss M, Blank J, Kahl BS. Bendamustine + rituximab chemoimmunotherapy and maintenance lenalidomide in relapsed, refractory chronic lymphocytic leukaemia and small lymphocytic lymphoma: A Wisconsin Oncology Network Study. Br J Haematol 2016; 173:283-91. [PMID: 26913697 DOI: 10.1111/bjh.13957] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/09/2015] [Indexed: 02/03/2023]
Abstract
Bendamustine + rituximab (BR) has demonstrated high response rates in relapsed/refractory (R/R) chronic lymphocytic leukaemia (CLL) and small lymphocytic lymphoma (SLL). However, progression-free survival (PFS) after BR is <18 months. This study was designed to determine if maintenance lenalidomide after BR induction could improve PFS in R/R CLL/SLL. Thirty-four patients with R/R CLL/SLL who had received 1-5 prior chemotherapy regimens were treated with 6 cycles of BR induction. Patients achieving at least a minor response received twelve 28-d cycles of lenalidomide 5-10 mg/d. The primary endpoint was PFS. The median age was 67 years, with a median of 2 prior therapies. Eleven patients had confirmed presence of 17p and/or 11q deletions. Twenty-five (74%) completed 6 cycles of induction BR (response rate 56%). Nineteen (56%) patients received maintenance lenalidomide; only 6 patients completed the intended 12 cycles, highlighting the limited feasibility of lenalidomide in this setting, primarily due to haematological and infectious toxicities. The observed median PFS of 18·3 months is not significantly different from that of BR induction in R/R CLL/SLL without maintenance therapy (15·2 months). It is possible that lenalidomide maintenance may be more feasible and effective in the front-line setting, which is being tested in an ongoing trial (NCT01754857).
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Affiliation(s)
- Julie E Chang
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Thomas Havighurst
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - KyungMann Kim
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Jens Eickhoff
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Anne M Traynor
- Department of Medicine, University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Rachel Kirby-Slimp
- University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Lynn M Volk
- University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | - Jae Werndli
- University of Wisconsin School of Medicine and Public Health and the UW Carbone Cancer Center, Madison, WI, USA
| | | | | | - Jules Blank
- Green Bay Oncology and the Saint Vincent Regional Cancer Center, Green Bay, WI, USA
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9
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Österborg A, Udvardy M, Zaritskey A, Andersson PO, Grosicki S, Mazur G, Kaplan P, Steurer M, Schuh A, Montillo M, Kryachok I, Middeke JM, Kulyaba Y, Rekhtman G, Gorczyca M, Daly S, Chang CN, Lisby S, Gupta I. Phase III, randomized study of ofatumumab versus physicians’ choice of therapy and standard versus extended-length ofatumumab in patients with bulky fludarabine-refractory chronic lymphocytic leukemia. Leuk Lymphoma 2016; 57:2037-46. [DOI: 10.3109/10428194.2015.1122783] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Wendtner CM, Hallek M, Fraser GAM, Michallet AS, Hillmen P, Dürig J, Kalaycio M, Gribben JG, Stilgenbauer S, Buhler A, Kipps TJ, Purse B, Zhang J, De Bedout S, Mei J, Chanan-Khan A. Safety and efficacy of different lenalidomide starting doses in patients with relapsed or refractory chronic lymphocytic leukemia: results of an international multicenter double-blinded randomized phase II trial. Leuk Lymphoma 2016; 57:1291-9. [PMID: 26763349 DOI: 10.3109/10428194.2015.1128540] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The objective of this study was to evaluate the safety and efficacy of different lenalidomide starting doses in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). CLL patients were randomized to receive lenalidomide at initial doses of 5, 10, or 15 mg/d (N = 103). Doses were escalated by 5 mg every 28-d up to a maximum of 25 mg/d; dose reductions in up to 5 mg decrements were permitted. The most common grade ≥3 adverse events (AEs) were neutropenia and thrombocytopenia. Ten patients died during therapy (four deaths considered as related to lenalidomide); 12 patients experienced second primary malignancies. The most common cause for treatment discontinuation was AEs. Overall response rates were similar across arms. Progression-free survival and overall survival rates were longer in patients who escalated treatment (to 15 or 20 mg/d) versus those who did not. Lower starting doses allowed subsequent dose escalation of lenalidomide while maintaining an acceptable tolerability profile in patients with relapsed/refractory CLL.
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Affiliation(s)
- Clemens M Wendtner
- a Klinikum Schwabing, Academic Teaching Hospital of University of Munich , Munich , Germany ;,b Department I of Internal Medicine , University of Cologne , Cologne , Germany
| | - Michael Hallek
- b Department I of Internal Medicine , University of Cologne , Cologne , Germany ;,c Cologne Cluster of Excellence in Cellular Stress Responses in Aging-Associated Diseases (CECAD) , Cologne , Germany
| | - Graeme A M Fraser
- d Juravinski Cancer Centre, McMaster University , Hamilton , Ontario , Canada
| | - Anne-Sophie Michallet
- e Hospices Civils De Lyon, Centre Hospitalier Lyon Sud , Pierre Bénite , Lyon , France
| | | | - Jan Dürig
- g University Hospital Essen , Essen , Germany
| | | | - John G Gribben
- i Barts Cancer Institute, Queen Mary, University of London , London , UK
| | | | - Andreas Buhler
- j Department of Internal Medicine III , Ulm University , Ulm , Germany
| | - Thomas J Kipps
- k University of California San Diego Moores Cancer Center , La Jolla , CA , USA
| | | | | | | | - Jay Mei
- l Celgene Corporation , Summit , NJ , USA
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11
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Sciumè M, Vincenti D, Reda G, Orofino N, Cassin R, Giannarelli D, Gaidano G, Rossi D, Cortelezzi A. Low-dose alemtuzumab in refractory/relapsed chronic lymphocytic leukemia: Genetic profile and long-term outcome from a single center experience. Am J Hematol 2015. [PMID: 26201283 DOI: 10.1002/ajh.24127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Relapsed/refractory chronic lymphocytic leukemia (CLL) represents a clinical challenge, in particular when high risk gene mutations occur. In this setting, alemtuzumab was recognized to be effective. This retrospective study evaluates long-term efficacy and tolerability of low-dose alemtuzumab in relapsed/refractory CLL and correlates clinical outcome with biological feature. Sixty-two consecutive patients (median age 68 years) were evaluated; alemtuzumab was administered 30 mg weekly for up to 18 weeks. Among the patients included in the analysis, 37% were fludarabine-refractory, 33.3% carried a TP53 disruption, 14.8% a NOTCH1 mutation and 9% a SF3B1 mutation. Overall response rate (ORR) was 61.3% (complete remission 25.8%). After a median follow-up of 43 months, overall survival (OS) and progression free survival (PFS) were 43.1 and 15 months, respectively; while ORR was 77.8% for patients carrying TP53 disruptions (OS 33.8 months) and 43.5% for fludarabine-refractory patients (OS 30 months). Noteworthy, long-term survivors (OS ≥ 36 months) were 54.8%. None of the biological poor risk factors negatively impacted on ORR, PFS and OS. Grade ≥3 cytopenia occurred in 24.2% patients, 6.5% experienced a grade ≥3 non-CMV infection and no grade ≥3 CMV-event occurred. In conclusion, low dose-alemtuzumab is safe and effective in relapsed/refractory CLL, also in a long-term follow-up and high-risk genetic subgroups.
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Affiliation(s)
- Mariarita Sciumè
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
| | - Daniele Vincenti
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
| | - Gianluigi Reda
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
| | - Nicola Orofino
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
| | - Ramona Cassin
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
| | - Diana Giannarelli
- Biostatistics Unit, Regina Elena Institute for Cancer Research and Treatment; via Elio Chianesi, 53 Rome Italy
| | - Gianluca Gaidano
- Division of Hematology; Dept. Of Translational Medicine; A. Avogadro University of Eastern Piedmont; Corso, Mazzini, 18 Novara Italy
| | - Davide Rossi
- Division of Hematology; Dept. Of Translational Medicine; A. Avogadro University of Eastern Piedmont; Corso, Mazzini, 18 Novara Italy
| | - Agostino Cortelezzi
- Hematology Unit, IRCCS Ca'granda Ospedale Maggiore Policlinico and University of Milan; via Francesco Sforza, 35 Milan Italy
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12
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A phase 2 study of idelalisib plus rituximab in treatment-naïve older patients with chronic lymphocytic leukemia. Blood 2015; 126:2686-94. [PMID: 26472751 DOI: 10.1182/blood-2015-03-630947] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 09/08/2015] [Indexed: 01/19/2023] Open
Abstract
Idelalisib is a first-in-class oral inhibitor of PI3Kδ that has shown substantial activity in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). To evaluate idelalisib as initial therapy, 64 treatment-naïve older patients with CLL or small lymphocytic leukemia (median age, 71 years; range, 65-90) were treated with rituximab 375 mg/m(2) weekly ×8 and idelalisib 150 mg twice daily continuously for 48 weeks. Patients completing 48 weeks without progression could continue to receive idelalisib on an extension study. The median time on treatment was 22.4 months (range, 0.8-45.8+). The overall response rate (ORR) was 97%, including 19% complete responses. The ORR was 100% in patients with del(17p)/TP53 mutations and 97% in those with unmutated IGHV. Progression-free survival was 83% at 36 months. The most frequent (>30%) adverse events (any grade) were diarrhea (including colitis) (64%), rash (58%), pyrexia (42%), nausea (38%), chills (36%), cough (33%), and fatigue (31%). Elevated alanine transaminase/aspartate transaminase was seen in 67% of patients (23% grade ≥3). The combination of idelalisib and rituximab was highly active, resulting in durable disease control in treatment-naïve older patients with CLL. These results support the further development of idelalisib as initial treatment of CLL. This study is registered at ClinicalTrials.gov as #NCT01203930.
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13
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Frustaci AM, Tedeschi A, Picardi P, Cairoli R, Montillo M. Clinical utility and patient considerations in the use of ofatumumab in chronic lymphocytic leukemia. Biologics 2015; 9:75-86. [PMID: 26425075 PMCID: PMC4583123 DOI: 10.2147/btt.s60503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Treatment aim for chronic lymphocytic leukemia has been radically changed over the past years from providing only a palliative approach to reaching disease eradication and improving survival. Ofatumumab is a monoclonal humanized antibody with peculiar in vitro and in vivo properties, at present approved for double fludarabine and alemtuzumab refractory chronic lymphocytic leukemia. Its efficacy in this subset of patients, who typically have an unfavorable prognosis, facilitated its use in different Phase II and III trials. Ofatumumab as single agent or combined with chemotherapeutic or biologic agents, led to sundry results in the setting of both previously treated or untreated patients. Its role in maintenance therapy is also under investigation. Further advances concerning ofatumumab administration as first line therapy in combination with chlorambucil, came recently from the COMPLEMENT 1 study. Results from this trial will open the door to new perspectives of its use in treatment-naïve patients. Ofatumumab was well tolerated in almost all the studies, with the main adverse events relating mostly to infusion reaction. Hematologic toxicity, especially neutropenia, was also common. A significant improvement in patients' quality of life was reported following ofatumumab treatment and this was mainly due to its effect on constitutional symptoms. Nevertheless, some concerns remain regarding the long-term efficacy of the drug in terms of response duration and survival. The real strength of this drug needs to be confirmed by further studies and direct comparative trials.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
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14
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Presence of multiple recurrent mutations confers poor trial outcome of relapsed/refractory CLL. Blood 2015; 126:2110-7. [PMID: 26316624 DOI: 10.1182/blood-2015-05-647578] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/15/2015] [Indexed: 12/22/2022] Open
Abstract
Although TP53, NOTCH1, and SF3B1 mutations may impair prognosis of patients with chronic lymphocytic leukemia (CLL) receiving frontline therapy, the impact of these mutations or any other, alone or in combination, remains unclear at relapse. The genome of 114 relapsed/refractory patients included in prospective trials was screened using targeted next-generation sequencing of the TP53, SF3B1, ATM, NOTCH1, XPO1, SAMHD1, MED12, BIRC3, and MYD88 genes. We performed clustering according to both number and combinations of recurrent gene mutations. The number of genes affected by mutation was ≥ 2, 1, and 0 in 43 (38%), 49 (43%), and 22 (19%) respectively. Recurrent combinations of ≥ 2 mutations of TP53, SF3B1, and ATM were found in 22 (19%) patients. This multiple-hit profile was associated with a median progression-free survival of 12 months compared with 22.5 months in the remaining patients (P = .003). Concurrent gene mutations are frequent in patients with relapsed/refractory CLL and are associated with worse outcome.
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15
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A review of monoclonal antibody therapies in lymphoma. Crit Rev Oncol Hematol 2015; 97:72-84. [PMID: 26318093 DOI: 10.1016/j.critrevonc.2015.08.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/03/2015] [Accepted: 08/05/2015] [Indexed: 12/27/2022] Open
Abstract
Monoclonal antibodies (moAb) represent a novel way of delivering therapy through specific target antigens expressed on lymphoma cells and minimizes the collateral damage that is common with conventional chemotherapy. The paradigm of this approach is the targeting of CD20 by rituximab. Since its FDA approval in 1997, rituximab has become the standard of care in almost every line of therapy in most B-cell lymphomas. This review will briefly highlight some of the key rituximab trials while looking more closely at the evidence that is bringing other antibodies, including next generation anti-CD20 moAbs, and anti-CD30 moAbs, among others to the forefront of lymphoma therapy.
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16
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Cuesta-Mateos C, Loscertales J, Kreutzman A, Colom-Fernández B, Portero-Sáinz I, Pérez-Villar JJ, Terrón F, Muñoz-Calleja C. Preclinical activity of anti-CCR7 immunotherapy in patients with high-risk chronic lymphocytic leukemia. Cancer Immunol Immunother 2015; 64:665-76. [PMID: 25724841 PMCID: PMC11029146 DOI: 10.1007/s00262-015-1670-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 02/14/2015] [Indexed: 01/05/2023]
Abstract
Chronic lymphocytic leukemia (CLL) with deletions of the p53 locus on chromosome 17 and/or refractory to fludarabine chemoimmunotherapy remains a major clinical problem with few therapeutic options. Currently, these types of CLL are treated with approaches that do not target the p53 pathway, such as small molecules and monoclonal antibodies (mAb). We have previously postulated anti-CCR7 mAb therapy as a novel CLL treatment. In the present study, we evaluated the in vitro efficacy of anti-CCR7 mAb as a single agent in CLL patients with high-risk cytogenetics and/or refractory to fludarabine, by measuring CCR7 surface expression and complement-dependent cytotoxicity. Our results demonstrate that CCR7 is highly expressed in challenging and heavily treated CLL patients. In addition, the complement-mediated mechanism of action of this mAb effectively eradicates CLL cells while sparing subsets of T cells in these patients. Moreover, this mAb outperformed the activity of alemtuzumab, the mAb with the highest efficacy in these groups. Finally, in vitro activity was also demonstrated in patients with a disease refractory to both fludarabine and alemtuzumab, and patients harboring 11q22 deletion. Our results propose that anti-CCR7 mAb is an effective and promising future treatment in high-risk CLL.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Murine-Derived/pharmacology
- Genes, p53
- Humans
- Immunophenotyping
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Receptors, CCR7/antagonists & inhibitors
- Receptors, CCR7/biosynthesis
- Receptors, CCR7/genetics
- Receptors, CCR7/immunology
- Risk Factors
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Affiliation(s)
- Carlos Cuesta-Mateos
- Servicio de Inmunología, Departamento de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain,
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17
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Abstract
In this issue of Blood, Jain et al reported on the poor outcomes of patients with chronic lymphocytic leukemia (CLL) after the discontinuation of ibrutinib.
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18
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Shimada N, Yuji K, Ohno N, Koibuchi T, Oyaizu N, Uchimaru K, Tojo A. Treatment of chronic lymphocytic leukemia with bendamustine in an HIV-infected patient on antiretroviral therapy: a case report and review of the literature. Clin Case Rep 2015; 3:453-60. [PMID: 26185648 PMCID: PMC4498862 DOI: 10.1002/ccr3.244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 01/28/2015] [Accepted: 02/20/2015] [Indexed: 12/19/2022] Open
Abstract
Few reports have described the coincidence of chronic lymphocytic leukemia (CLL) and HIV. We administered bendamustine to an HIV-positive refractory CLL patient and obtained a significant objective response. Our results indicate that bendamustine can be used in HIV-infected CLL patients. We also reviewed 12 cases of CLL with HIV infection.
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Affiliation(s)
- Naoki Shimada
- Promotion Plan for the Platform of Human Resource Development for Cancer, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Koichiro Yuji
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Nobuhiro Ohno
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Tomohiko Koibuchi
- Department of Infectious Diseases and Applied Immunology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Naoki Oyaizu
- Department of Laboratory Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Kaoru Uchimaru
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
| | - Arinobu Tojo
- Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo Tokyo, Japan
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19
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Österborg A, Wierda WG, Mayer J, Hess G, Hillmen P, Schetelig J, Schuh A, Smolej L, Beck C, Dreyfus B, Hellman A, Kozlowski P, Pfreundschuh M, Rizzi R, Spacek M, Phillips JL, Gupta IV, Williams V, Jewell RC, Nebot N, Lisby S, Dyer MJS. Ofatumumab retreatment and maintenance in fludarabine-refractory chronic lymphocytic leukaemia patients. Br J Haematol 2015; 170:40-9. [DOI: 10.1111/bjh.13380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/04/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Anders Österborg
- Department of Haematology; Karolinska University Hospital; Stockholm Sweden
| | - William G. Wierda
- The University of Texas; M.D. Anderson Cancer Center; Houston TX USA
- Cancer Therapy Research Center; San Antonio TX USA
| | - Jiří Mayer
- Department of Internal Medicine/Haemato-Oncology; Faculty Hospital Brno; Brno Czech Republic
| | - Georg Hess
- Johannes-Gutenberg-Universtitaer Mainz; Mainz Germany
| | | | | | | | - Lukáš Smolej
- Faculty of Medicine in Hradec Kralove; University Hospital and Charles University in Prague; Hradec Kralove Czech Republic
| | - Christian Beck
- Haematologisch-Onkologisches Institut; Moenchengladbach-Rheydt Germany
| | | | | | | | | | - Rita Rizzi
- Azienda Ospendaliero Universitaria Policlinico Consorziale; Bari Italy
| | | | | | | | | | | | | | | | - Martin J. S. Dyer
- Ernest and Helen Scott Haematological Research Institute; University of Leicester; Leicester UK
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20
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Österborg A, Jewell RC, Padmanabhan-Iyer S, Kipps TJ, Mayer J, Stilgenbauer S, Williams CD, Hellmann A, Furman RR, Robak T, Hillmen P, Trnêný M, Dyer MJS, Piotrowska M, Kozak T, Gupta IV, Phillips JL, Goldstein N, Struemper H, Losic N, Lisby S, Wierda WG. Ofatumumab monotherapy in fludarabine-refractory chronic lymphocytic leukemia: final results from a pivotal study. Haematologica 2015; 100:e311-4. [PMID: 25769539 DOI: 10.3324/haematol.2014.121459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Anders Österborg
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Swami Padmanabhan-Iyer
- Cancer Therapy Research Center, San Antonio, TX, USA (formerly Roswell Park Cancer Institute, Buffalo, NY, USA)
| | | | - Jiří Mayer
- Faculty Hospital Brno, Dept of Internal Medicine/Hemato-Oncology, Czech Republic
| | | | - Cathy D Williams
- Center for Clinical Haematology, Nottingham University Hospitals, UK
| | | | - Richard R Furman
- Weill Cornell Medical College, Division of Hematology/Oncology, New York, NY, USA
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Poland
| | - Peter Hillmen
- St James' Institute of Oncology, St James' University Hospital, Leeds, UK
| | - Marek Trnêný
- First Faculty of Medicine, Charles University General Hospital, Prague, Czech Republic
| | - Martin J S Dyer
- The Ernest and Helen Scott Haematological Research Institute, University of Leicester, UK
| | | | - Tomas Kozak
- University Hospital Kralovske Vinohrady, Department of Clinical Hematology, Prague, Czech Republic
| | | | | | | | | | | | | | - William G Wierda
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
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21
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Final results of EFC6663: a multicenter, international, phase 2 study of alvocidib for patients with fludarabine-refractory chronic lymphocytic leukemia. Leuk Res 2015; 39:495-500. [PMID: 25804339 DOI: 10.1016/j.leukres.2015.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/29/2015] [Accepted: 02/01/2015] [Indexed: 12/14/2022]
Abstract
Early phase studies of alvocidib showed activity in relapsed CLL including patients with high risk genomic features and those refractory to fludarabine. A multi-center, international, phase II study of alvocidib in fludarabine refractory CLL was undertaken to validate these early results. Patients with fludarabine refractory CLL or prolymphocytic leukemia arising from CLL were treated with single agent alvocidib. The primary outcome measure was overall response rate, with secondary outcomes including survival, toxicity, and response duration. One hundred and sixty five patients were enrolled and 159 patients were treated. The median age was 61 years, the median number of prior therapies was 4, and 96% of patients were fludarabine refractory. The investigator-assessed overall response rate was 25%; the majority of responses were partial. Response rates were lower among patients with del(17p) (14%), but equivalent in patients with del(11q) or bulky lymphadenopathy. Median progression free and overall survival were 7.6 and 14.6 months, respectively. Tumor lysis occurred in 39 patients (25%), and 13 received hemodialysis. Diarrhea, fatigue, and hematologic toxicities were common. Alvocidib has clinical activity in patients with advanced, fludarabine refractory CLL. Future studies should focus on discovery of biomarkers of clinical response and tumor lysis, and enhanced supportive care measures.
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22
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Durot E, Michallet AS, Leprêtre S, Le QH, Leblond V, Delmer A. Platinum and high-dose cytarabine-based regimens are efficient in ultra high/high-risk chronic lymphocytic leukemia and Richter's syndrome: results of a French retrospective multicenter study. Eur J Haematol 2015; 95:160-7. [DOI: 10.1111/ejh.12474] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 01/04/2023]
Affiliation(s)
- Eric Durot
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
| | | | - Stéphane Leprêtre
- Département d'Hématologie, Unicancer; Centre Henri Becquerel; Rouen France
| | - Quoc-Hung Le
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
| | - Véronique Leblond
- AP-HP; Service d'Hématologie Clinique; Hôpital Pitié-Salpêtrière; Paris France
- UPMC Université Paris 06 GRC11-GRECHY; Paris France
| | - Alain Delmer
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
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23
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Ofatumumab and high-dose methylprednisolone for the treatment of patients with relapsed or refractory chronic lymphocytic leukemia. Blood Cancer J 2014; 4:e258. [PMID: 25397619 PMCID: PMC4571984 DOI: 10.1038/bcj.2014.76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/06/2014] [Indexed: 12/12/2022] Open
Abstract
Ofatumumab is a humanized anti-CD20 monoclonal antibody that has been approved by the FDA for the treatment of patients with chronic lymphocytic leukemia. We conducted a phase II single-arm study at a single center. Patients received ofatumumab (300 mg then 1000 mg weekly for 12 weeks) and methylprednisolone (1000 mg/m2 for 3 days of each 28-day cycle). Twenty-one patients enrolled, including 29% with unfavorable cytogenetics (del17p or del11q). Ninety percent of patients received the full course without dose reductions or delays. The overall response rate was 81% (17/21) with 5% complete response, 10% nodular partial response, 67% partial response, 14% stable disease and 5% progressive disease. After a median follow-up of 31 months, the median progression-free survival was 9.9 months and the median time to next treatment was 12.1 months. The median overall survival has not yet been reached. The combination of high-dose methylprednisolone and ofatumumab is an effective and tolerable treatment regimen. This regimen may be useful for patients who are unable to tolerate more aggressive therapies, or have not responded to other treatments.
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24
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Sobecks RM, Leis JF, Gale RP, Ahn KW, Zhu X, Sabloff M, de Lima M, Brown JR, Inamoto Y, Hale GA, Aljurf MD, Kamble RT, Hsu JW, Pavletic SZ, Wirk B, Seftel MD, Lewis ID, Alyea EP, Cortes J, Kalaycio ME, Maziarz RT, Saber W. Outcomes of human leukocyte antigen-matched sibling donor hematopoietic cell transplantation in chronic lymphocytic leukemia: myeloablative versus reduced-intensity conditioning regimens. Biol Blood Marrow Transplant 2014; 20:1390-8. [PMID: 24880021 PMCID: PMC4174349 DOI: 10.1016/j.bbmt.2014.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/21/2014] [Indexed: 11/19/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can cure some chronic lymphocytic leukemia (CLL) subjects. This study compared outcomes of myeloablative (MA) and reduced-intensity conditioning (RIC) transplants from HLA-matched sibling donors (MSD) for CLL. From 1995 to 2007, information regarding 297 CLL subjects was reported to the Center of International Blood and Marrow Transplant Research; of these, 163 underwent MA and 134 underwent RIC MSD HCT. The MA subjects underwent transplantation less often after 2000 and less commonly received antithymocyte globulin (4% versus 13%, P = .004) or prior antibody therapy (14% versus 53%; P < .001). RIC was associated with a greater likelihood of platelet recovery and less grade 2 to 4 acute graft-versus-host disease compared with MA conditioning. One- and 5-year treatment-related mortality (TRM) were 24% (95% confidence intervals [CI], 16% to 33%) versus 37% (95% CI, 30% to 45%; P = .023), and 40% (95% CI, 29% to 51%) versus 54% (95% CI, 46% to 62%; P = .036), respectively, and the relapse/progression rates at 1 and 5 years were 21% (95% CI, 14% to 29%) versus 10% (95% CI, 6% to 15%; P = .020), and 35% (95% CI, 26% to 46%) versus 17% (95% CI, 12% to 24%; P = .003), respectively. MA conditioning was associated with better progression-free (PFS) (relative risk, .60; 95% CI, .37 to .97; P = .038) and 3-year survival in transplantations before 2001, but for subsequent years, RIC was associated with better PFS and survival (relative risk, 1.49 [95% CI, .92 to 2.42]; P = .10; and relative risk, 1.86 [95% CI, 1.11 to 3.13]; P = .019). Pretransplantation disease status was the most important predictor of relapse (P = .003) and PFS (P = .0007) for both forms of transplantation conditioning. MA and RIC MSD transplantations are effective for CLL. Future strategies to decrease TRM and reduce relapses are warranted.
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Affiliation(s)
- Ronald M Sobecks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jose F Leis
- Department of Hematology/Oncology, Mayo Clinic Arizona, Phoenix, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert Peter Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Centre, Imperial College London, London, United Kingdom
| | - Kwang Woo Ahn
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mitchell Sabloff
- Divison of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marcos de Lima
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jennifer R Brown
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Gregory A Hale
- Department of Hematology/Oncology, All Children's Hospital, St. Petersburg, Florida
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Rammurti T Kamble
- Department of Hematology/Oncology, Baylor College of Medicine, Center for Cell and Gene Therapy, Houston, Texas
| | - Jack W Hsu
- Division of Hematology & Oncology, Department of Medicine, Shands HealthCare and University of Florida, Gainesville, Florida
| | - Steven Z Pavletic
- National Institutes of Health-National Cancer Institute Experimental Transplantation and Immunology Branch, Bethesda, Maryland
| | - Baldeep Wirk
- Stony Brook University Medical Center, Stony Brook, New York
| | - Matthew D Seftel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ian D Lewis
- Royal Adelaide Hospital, Adelaide, Australia
| | - Edwin P Alyea
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jorge Cortes
- Department of Leukemia, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Matt E Kalaycio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, Oregon
| | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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25
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Sabloff M, Sobecks RM, Ahn KW, Zhu X, de Lima M, Brown JR, Inamoto Y, Holland HK, Aljurf MD, Laughlin MJ, Kamble RT, Hsu JW, Wirk BM, Seftel M, Lewis ID, Arora M, Alyea EP, Kalaycio ME, Cortes J, Maziarz RT, Gale RP, Saber W. Does total body irradiation conditioning improve outcomes of myeloablative human leukocyte antigen-identical sibling transplantations for chronic lymphocytic leukemia? Biol Blood Marrow Transplant 2014; 20:421-4. [PMID: 24321745 PMCID: PMC4026353 DOI: 10.1016/j.bbmt.2013.11.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
An allogeneic hematopoietic cell transplantation from an HLA-identical donor after high-dose (myeloablative) pretransplantation conditioning is an effective therapy for some people with chronic lymphocytic leukemia (CLL). Because CLL is a highly radiosensitive cancer, we hypothesized that total body irradiation (TBI) conditioning regimens may be associated with better outcomes than those without TBI. To answer this, we analyzed data from 180 subjects with CLL receiving myeloablative doses of TBI (n = 126) or not (n = 54), who received transplants from an HLA-identical sibling donor between 1995 and 2007 and reported to the Center for International Blood & Marrow Transplant Research. At 5 years, treatment-related mortality was 48% (95% confidence interval [CI], 39% to 57%) versus 50% (95% CI, 36% to 64%); P = NS. Relapse rates were 17% (95% CI, 11% to 25%) versus 22% (95% CI, 11% to 35%); P = NS. Five-year progression-free survival and overall survival were 34% (95% CI, 26% to 43%) versus 28% (95% CI, 15% to 42%); P = NS and 42% (95% CI, 33% to 51%) versus 33% (95% CI, 19% to 48%); P = NS, respectively. The single most common cause of death in both cohorts was recurrent/progressive CLL. No variable tested in the multivariate analysis was found to significantly affect these outcomes, including having failed fludarabine. Within the limitations of this study, we found no difference in HLA-identical sibling transplantation outcomes between myeloablative TBI and chemotherapy pretransplantation conditioning in persons with CLL.
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MESH Headings
- Adult
- Female
- HLA Antigens/immunology
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Middle Aged
- Myeloablative Agonists/therapeutic use
- Recurrence
- Siblings
- Survival Analysis
- Transplantation Conditioning/methods
- Transplantation, Isogeneic
- Treatment Outcome
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
- Whole-Body Irradiation
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Affiliation(s)
- Mitchell Sabloff
- Division of Hematology, Department of Medicine, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ronald M Sobecks
- Division of Hematologic Oncology and Blood Disorders, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kwang Woo Ahn
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Center for International Blood & Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcos de Lima
- Division of Hematologic Malignancies and Stem Cell Transplantation, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jennifer R Brown
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Yoshihiro Inamoto
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - H Kent Holland
- Division of Oncology and Hematology, The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, Georgia
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Mary J Laughlin
- Hematopoietic Cell Transplantation Program, University Hospitals Case Medical Center, University of Virginia Health System, Charlottesville, Virginia
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | - Jack W Hsu
- Division of Hematology and Oncology, Department of Medicine, Shands Healthcare & University of Florida, Gainesville, Florida
| | - Baldeep M Wirk
- Division of Hematology and Oncology, Stony Brook University Medical Center, Stony Brook, New York
| | - Matthew Seftel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ian D Lewis
- Haematology and Bone Marrow Transplant Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mukta Arora
- Division of Hematology, Oncology and Transplant, University of Minnesota Medical Center, Fairview, Minneapolis, Minneapolis
| | - Edwin P Alyea
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Matt E Kalaycio
- Division of Hematologic Oncology and Blood Disorders, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jorge Cortes
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Richard T Maziarz
- Center for Hematologic Malignancies, OHSU Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Robert Peter Gale
- Section of Hematology, Division of Experimental Medicine, Department of Medicine, Imperial College, London, United Kingdom
| | - Wael Saber
- Center for International Blood & Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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26
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Eketorp Sylvan S, Hansson L, Karlsson C, Norin S, Lundin J, Osterborg A. Outcomes of patients with fludarabine-refractory chronic lymphocytic leukemia: a population-based study from a well-defined geographic region. Leuk Lymphoma 2014; 55:1774-80. [PMID: 24237446 DOI: 10.3109/10428194.2013.827786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with fludarabine-refractory (FR) chronic lymphocytic leukemia (CLL) receive novel agents in pivotal, non-randomised phase-2 trials. Understanding outcome of FR-CLL in health-care may provide important contextual information. Records from 1301 patients (Stockholm-Cancer-Registry 1991-2010) identified 92 FR-patients; bulky lymph-nodes (BFR-group), double-refractory (DR-group), or Others'-group for outcome-analysis. Median age was 69 years 67% had Rai-stage III/IV with median 3 prior therapies. Overall response-rate was 20%; significantly lower in BFR (8%, p = 0.01) and DR (20%, p = 0.01) than in 'Others' (31%). Time-to-treatment-failure (months) was significantly longer in 'Others' (9.2) than in BFR/DR (5.3/4.4) (p < 0.01) and significantly longer (p < 0.05) in antibody-treated patients (9.1) compared to other regimens (5.2). Early-death occurred in 5%, ≥ grade III-infections in 20%. Median overall-survival (OS) was 18 months; 29 in BFR vs. 13 in DR (p = 0.054). Male sex was the only prognostic factor on OS (p = 0.01, HR 2.2, multivariate-Cox-regression). Our results, without external referrals, facilitate interpretation of non-randomised trials/novel drugs in advanced-stage-CLL.
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Affiliation(s)
- Sandra Eketorp Sylvan
- Departments of Hematology and Oncology, Karolinska University Hospital , Stockholm , Sweden
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27
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28
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Mehta RS, Di Stasi A, Hosing C, Shah N, Rezvani K, Alousi A, O'Brien S, Wierda W, Keating M, Shpall EJ. Lenalidomide-induced graft-vs.-Leukemia effect in a patient with chronic lymphocytic leukemia who relapsed after allogeneic stem cell transplant. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:e105-9. [PMID: 24502832 DOI: 10.1016/j.clml.2013.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 12/12/2013] [Accepted: 12/23/2013] [Indexed: 01/13/2023]
Affiliation(s)
- Rohtesh S Mehta
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Antonio Di Stasi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wierda
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Keating
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
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Bendamustine in combination with Ofatumumab in relapsed or refractory chronic lymphocytic leukemia: a GIMEMA Multicenter Phase II Trial. Leukemia 2013; 28:642-8. [DOI: 10.1038/leu.2013.334] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 11/04/2013] [Indexed: 12/13/2022]
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Kater AP, Spiering M, Liu RD, Doreen Te Raa G, Slinger E, Tonino SH, Beckers MM, Daenen S, Doorduijn JK, Lankheet NAG, Luijks DM, Eldering E, van Oers MHJ. Dasatinib in combination with fludarabine in patients with refractory chronic lymphocytic leukemia: a multicenter phase 2 study. Leuk Res 2013; 38:34-41. [PMID: 24238639 DOI: 10.1016/j.leukres.2013.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 09/07/2013] [Accepted: 10/04/2013] [Indexed: 01/16/2023]
Abstract
Resistance to chemotherapy-induced apoptosis in CLL is associated with overexpression of antiapoptotic proteins induced by signals from the microenvironment. In vitro, dasatinib effectively inhibits expression of anti-apoptotic regulators and restores fludarabine sensitivity in activated CLL. The aim of this study was to evaluate efficacy of one cycle of dasatinib monotherapy (100mg/day, days 1-28) followed by combination of dasatinib with fludarabine (40mg/m²/day, days 1-3 every 28 day) for a total of 6 cycles in fludarabine-refractory CLL. The primary endpoint was overall response rate according to the IWCLL'08 criteria. 20 patients were enrolled: 18 completed at least one cycle of treatment of which 67% finished at least 2 cycles of combination treatment. 3 of these 18 patients reached a formal PR (16.7%). Majority of patients obtained some reduction in lymph node (LN) size. Most frequent toxicity was related to myelosuppression. NF-κB RNA expression levels of circulating CLL cells decreased whereas the levels of pro-apoptotic NOXA increased during treatment. In conclusion, dasatinib/fludarabine combination has modest clinical efficacy in fludarabine-refractory patients.
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Affiliation(s)
- Arnon P Kater
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands; LYMMCARE (Lymphoma and Myeloma Center Amsterdam), The Netherlands.
| | - Marjolein Spiering
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Roberto D Liu
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - G Doreen Te Raa
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - E Slinger
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Sanne H Tonino
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands; LYMMCARE (Lymphoma and Myeloma Center Amsterdam), The Netherlands
| | | | - Simon Daenen
- University Medical Centre Groningen, The Netherlands
| | | | - Nienke A G Lankheet
- Department of Pharmacy & Pharmacology, Slotervaart Hospital/The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dieuwertje M Luijks
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Eric Eldering
- Laboratory of Experimental Medicine, Academic Medical Centre, Amsterdam, The Netherlands; LYMMCARE (Lymphoma and Myeloma Center Amsterdam), The Netherlands
| | - Marinus H J van Oers
- Department of Hematology, Academic Medical Centre, Amsterdam, The Netherlands; LYMMCARE (Lymphoma and Myeloma Center Amsterdam), The Netherlands
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Synergistic apoptotic response between valproic acid and fludarabine in chronic lymphocytic leukaemia (CLL) cells involves the lysosomal protease cathepsin B. Blood Cancer J 2013; 3:e153. [PMID: 24141622 PMCID: PMC3816211 DOI: 10.1038/bcj.2013.50] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/01/2013] [Accepted: 08/19/2013] [Indexed: 01/13/2023] Open
Abstract
Fludarabine, a nucleoside analogue, is commonly used in combination with other agents for the treatment of chronic lymphocytic leukaemia (CLL). In previous studies, valproic acid (VPA), an inhibitor of histone deacetylases, combined with fludarabine to synergistically increase apoptotic cell death in CLL cells. In the present study, we found that the combination of fludarabine and VPA decreases the level of the anti-apoptotic proteins Mcl-1 and XIAP in primary CLL cells. Treatment with fludarabine alone, or in combination with VPA, led to the loss of lysosome integrity, and chemical inhibition of the lysosomal protease cathepsin B, using CA074-Me, was sufficient to reduce apoptosis. VPA treatment increased cathepsin B levels and activities in primary CLL cells, thereby priming CLL cells for lysosome-mediated cell death. Six previously treated patients with relapsed CLL were treated with VPA, followed by VPA/fludarabine combination. The combined therapy resulted in reduced lymphocyte count in five out of six and reduced lymph node sizes in four out of six patients. In vivo VPA treatment increased histone-3 acetylation and cathepsin B expression levels. Thus, the synergistic apoptotic response with VPA and fludarabine in CLL is mediated by cathepsin B activation leading to a decrease in the anti-apoptotic proteins.
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Cuthill K, Devereux S. How I treat patients with relapsed chronic lymphocytic leukaemia. Br J Haematol 2013; 163:423-35. [DOI: 10.1111/bjh.12549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/29/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Kirsty Cuthill
- Department of Haematological Medicine; Kings College; London UK
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Overexpressed BAG3 is a potential therapeutic target in chronic lymphocytic leukemia. Ann Hematol 2013; 93:425-35. [DOI: 10.1007/s00277-013-1883-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 08/14/2013] [Indexed: 01/20/2023]
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Tumor protein p53 (TP53) testing and Li-Fraumeni syndrome : current status of clinical applications and future directions. Mol Diagn Ther 2013; 17:31-47. [PMID: 23355100 DOI: 10.1007/s40291-013-0020-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Prevalent as an acquired abnormality in cancer, the role of tumor protein p53 (TP53) as a germline mutation continues to evolve. The clinical impact of a germline TP53 mutation is often dramatic and affects the full life course, with a propensity to develop rare tumors in childhood and multiple common cancers of unexpectedly early onset in adulthood. In this article, we review the clinical relevance of germline mutations in the TP53 tumor suppressor gene to current healthcare practice, including the optimal ways to identify patients with Li-Fraumeni syndrome (LFS), to recognize the core cancers associated with LFS, and to develop strategies for early detection of LFS-associated tumors. Several TP53-targeted approaches to improve outcomes in LFS patients are also reviewed. A case report is used to highlight special TP53 testing dilemmas and unique challenges associated with genetic testing decisions in the current age of rapidly advancing genomic technologies.
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Abstract
Hematology Oncology has a rich history including few crucial therapeutic innovations. These were possible because of the evolution of the cell and molecular biology allowing a better understanding of basic mechanisms of cancerogenesis. We propose here to summarize the most important therapeutic innovations since the beginning of Hematology/Oncology history. We also describe evolution of therapeutic strategies themselves. New insights and therapeutic perspectives for next future are also discussed.
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NOTCH1, SF3B1, and TP53 mutations in fludarabine-refractory CLL patients treated with alemtuzumab: results from the CLL2H trial of the GCLLSG. Blood 2013; 122:1266-70. [PMID: 23821658 DOI: 10.1182/blood-2013-03-488197] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We studied the incidences, associations, and prognostic roles of NOTCH1 and SF3B1 mutations (NOTCH1(mut), SF3B1(mut)) as compared with TP53(mut) in fludarabine-refractory chronic lymphocytic leukemia (CLL) patients treated with alemtuzumab in the CLL2H trial. We found NOTCH1(mut), SF3B1(mut), and TP53(mut) in 13.4%, 17.5%, and 37.4% of patients, respectively. NOTCH1(mut) and SF3B1(mut) were mutually exclusive, whereas TP53(mut) were evenly distributed within both subgroups. Apart from correlation of SF3B1(mut) with 11q deletion (P = .029), there were no other significant associations of the mutations with any baseline characteristics or response rates. However, NOTCH1(mut) cases had a significantly longer progression-free survival (PFS) compared with wild-type cases (15.47 vs 6.74 months; P = .025), although there was no significant difference with overall survival (OS). SF3B1(mut) had no significant impact on PFS and OS. In multivariable analyses, NOTCH1(mut) was identified as an independent favorable marker for PFS. This clinical trial is registered at www.clinicaltrials.gov as #NCT00274976.
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37
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[Conventional therapeutic strategies for relapsed chronic lymphocytic leukemia]. Bull Cancer 2012; 99:1123-32. [PMID: 23249977 DOI: 10.1684/bdc.2012.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The choice of salvage therapy for patients presenting relapsed chronic lymphocytic leukemia (CLL) has to take into account some factors influencing tumor resistance and comorbidities. Since 2010, new drugs targeting the tumor cells' signaling have been proposed for CLL patients. Waiting the results of various clinical trials evaluating these treatments, there is a need to describe the state-of-the-art concerning approved treatments such as chemotherapy and monoclonal antibodies.
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Fonte E, Apollonio B, Scarfò L, Ranghetti P, Fazi C, Ghia P, Caligaris-Cappio F, Muzio M. In vitro sensitivity of CLL cells to fludarabine may be modulated by the stimulation of Toll-like receptors. Clin Cancer Res 2012; 19:367-79. [PMID: 23224401 DOI: 10.1158/1078-0432.ccr-12-1922] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The emerging role of Toll-like receptors (TLR) in the pathogenesis of chronic lymphocytic leukemia (CLL) led us to ask whether TLR stimulation may protect CLL cells from drug-induced apoptosis. EXPERIMENTAL DESIGN We cultured in vitro malignant B cells freshly isolated from 44 patients with CLLs in the presence or the absence of different concentrations of fludarabine before or after 24-hour TLR stimulation with specific ligands and evaluated cell viability, apoptosis, and molecular pathways involved. RESULTS Heterogeneity was observed among samples. In leukemic cells from patients bearing adverse prognostic factors, TLR stimulation caused a significant increase of protection to fludarabine treatment, whereas this did not occur in the cells from patients with good prognosis. To identify novel molecular mechanisms accounting for the dichotomy of response between the two groups of patients, we conducted an apoptosis gene expression profile on leukemic cells either unstimulated or stimulated with TLR9 ligand. Strikingly, TLR9 stimulation specifically upregulated the expression of lymphotoxin-α in cells where an increased protection to fludarabine treatment was observed. Also, the expression of miR-155-3p was significantly increased after stimulation of distinct TLR in cells where fludarabine treatment was less effective. CONCLUSIONS These results suggest that at least in a proportion of patients, in vitro sensitivity to fludarabine may be modulated by the stimulation of TLR, likely mimicking microenvironmental signals occurring in vivo.
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Affiliation(s)
- Eleonora Fonte
- San Raffaele Scientific Institute, Division of Molecular Oncology; Università Vita-Salute San Raffaele, Via Olgettina 58, Milan, Italy
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Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) often has an extended disease course. With a median age at diagnosis of 72 years, newer treatment options with less toxicity than standard nucleoside analogue-based regimens are needed. Historically, few therapy options are available once CLL has become refractory to nucleoside analogues. Bendamustine has emerged as a feasible therapy for older and less fit CLL patients, with clinical efficacy in previously untreated and refractory CLL. AREAS COVERED This paper reviews several of the pivotal clinical trials that established the clinical activity of bendamustine in previously untreated and relapsed/refractory CLL. The toxicity profile of bendamustine, primarily myelosuppression and infections, is reviewed and compared across different CLL populations. A review of the clinical data focuses on potential explanations for differences in response rates and duration of remission reported across studies and how this may impact the development of therapies for CLL. EXPERT OPINION Bendamustine is a valuable new agent for the management of CLL. Ongoing clinical trials are comparing bendamustine with standard CLL regimens in untreated disease, and investigating bendamustine combinations with novel targeted therapies and monoclonal antibodies. These studies will help to define the optimal role for bendamustine in CLL management.
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Affiliation(s)
- Julie Elizabeth Chang
- University of Wisconsin - Medicine, 1111 Highland Avenue, Madison, WI 53705-2275, USA.
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Veliz M, Pinilla-Ibarz J. Treatment of relapsed or refractory chronic lymphocytic leukemia. Cancer Control 2012; 19:37-53. [PMID: 22143061 DOI: 10.1177/107327481201900105] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent advances in the treatment of chronic lymphocytic leukemia (CLL) have moved beyond the traditional use of alkylating agents and purine analogs into regimens combining these two chemotherapy classes with monoclonal antibodies. METHODS This article reviews treatments options for patients with relapsed or refractory CLL. RESULTS Several studies have investigated novel agents in treating patients with 17p deletion, TP53 mutation, and fludarabine-refractory CLL, as well as patients with suboptimal response to intense treatment. These investigational agents include rituximab, alemtuzumab, ofatumumab, bendamustine, high-dose methylprednisolone, lenalidomide, lumiliximab, cyclin-dependent kinase inhibitors, small modular immunopharmaceuticals, Bcl-2 inhibitors, and histone deacetylase inhibitors. While these newer drugs and combination therapies have shown promise as treatment options for CLL, additional studies are needed to determine the immunosuppression, toxicities, and infections associated with their use. CONCLUSIONS Despite improvement in initial overall response rates, most patients relapse and require further treatment. CLL remains incurable with standard therapies due to development of disease refractoriness. As such, novel approaches such as those noted above warrant continued research to improve outcomes for patients with CLL.
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Affiliation(s)
- Marays Veliz
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Smolej L. The role of high-dose corticosteroids in the treatment of chronic lymphocytic leukemia. Expert Opin Investig Drugs 2012; 21:1009-17. [PMID: 22616646 DOI: 10.1517/13543784.2012.690393] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Management of refractory chronic lymphocytic leukemia (CLL) represents a major challenge because of the poor prognosis and limited treatment options. While corticosteroids have been used to treat CLL since 1940s, their benefit has never been conclusively proved. Recently, several groups reported use of high-dose corticosteroids (methylprednisolone or dexamethasone) either alone or combined with chemotherapy and/or monoclonal antibodies in relapsed/refractory CLL. AREAS COVERED While efficacy of high-dose corticosteroids is excellent including responses in patients with bulky lymphadenopathy or those considered ultra high-risk CLL because of deletion and/or mutation of p53 gene, the duration of response is still unsatisfactory. Combination with monoclonal antibodies seems to improve therapeutic efficacy but no randomized trials have been conducted. For the purpose of this review, a search for terms, high-dose corticosteroids/methylprednisolone/dexamethasone, and chronic lymphocytic leukemia has been performed in PubMed and database of abstracts from American Society of Hematology Meetings. EXPERT OPINION High-dose corticosteroids appear to play an important role in the management of highly pretreated relapsed/refractory CLL including patients with massive lymphadenopathy. Myelosuppression is usually limited but infectious toxicity, including increased risk of invasive fungal infections, represents the most dreaded side effects. This therapeutic approach should be further tested within large prospective trials, to optimize efficacy and safety.
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Affiliation(s)
- Lukáš Smolej
- University Hospital and Faculty of Medicine, Second Department of Medicine, Department of Hematology, Sokolská 581, 500 05 Hradec Králové, Czech Republic.
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42
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Boulassel MR. A new cellular weapon to kill leukaemic B-cells. Sultan Qaboos Univ Med J 2012; 12:137-9. [PMID: 22548131 DOI: 10.12816/0003105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/21/2012] [Accepted: 03/13/2012] [Indexed: 11/27/2022] Open
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Bazargan A, Tam CS, Keating MJ. Predicting survival in chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2012; 12:393-403. [PMID: 22369330 DOI: 10.1586/era.12.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is increasing interest in the use of prognostic markers that may predict survival and guide management in patients diagnosed with the early stages of chronic lymphocytic leukemia (CLL). Currently, the most important traditional prognostic factors include clinical staging, lymphocyte doubling time and β2-microglobulin/thymidine kinase; and the most important novel markers include karyotypic aberrations (typically assessed by FISH probes or CpG oligonucleotide karyotyping) and IgVH mutation status. Although each of these factors have individually shown significant correlations with survival, there is increasing appreciation that the most complete information may be obtained by using a combination of several factors in prognostic normograms or models. In this article, we review the current state-of-the-art with regards to CLL prognostic factors and discuss how they can be applied in the clinic.
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Affiliation(s)
- Ali Bazargan
- Hematology Department, St Vincent's Hospital, Melbourne, VIC, Australia
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[Economic evaluation of rituximab added to fludarabine plus cyclophosphamide versus fludarabine plus cyclophosphamide for the treatment of chronic lymphocytic leukemia]. GACETA SANITARIA 2011; 25:274-81. [PMID: 21664727 DOI: 10.1016/j.gaceta.2011.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Revised: 03/04/2011] [Accepted: 03/04/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We evaluated the cost-effectiveness of rituximab added to the chemotherapy regimen of fludarabine plus cyclophosphamide (R-FC) versus fludarabine plus cyclophosphamide (FC) for the treatment of patients with previously untreated or relapsed/refractory chronic lymphocytic leukemia (CLL). METHODS Two Markov models were built, using published results on progression-free survival (PFS) in patients receiving first- or second-line therapy with R-FC vs FC, rates of disease progression and mortality rates in Spain. Patient-elicited utilities were applied to PFS and progressed health states. The cost of drugs, supportive care, and quality-adjusted life years (QALY) were estimated over a 10-year period. Univariate and probabilistic (Monte Carlo) sensitivity analyses were performed. RESULTS The addition of rituximab to chemotherapy in first- and second-line therapy increased life-years gained (LYG) and QALYs compared with chemotherapy. The incremental cost per LYG and QALY gained was €20,703 and €19,343 for first-line treatment and was €23,183 and €24,781 for second-line treatment. CONCLUSION In patients with previously untreated or relapsed/refractory CLL, the addition of rituximab to the FC regimen increased life expectancy and quality-adjusted life expectancy. In both types of patient, the treatment was cost-effective.
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Lepretre S, Jäger U, Janssens A, Leblond V, Nikitin E, Robak T, Wendtner CM. The value of rituximab for the treatment of fludarabine-refractory chronic lymphocytic leukemia: a systematic review and qualitative analysis of the literature. Leuk Lymphoma 2011; 53:820-9. [DOI: 10.3109/10428194.2011.631636] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Żołnierczyk JD, Komina O, Błoński JZ, Borowiak A, Cebula-Obrzut B, Smolewski P, Robak P, Kiliańska ZM, Węsierska-Gądek J. Can ex vivo evaluation (testing) predict the sensitivity of CLL cells to therapy with purine analogs in conjunction with an alkylating agent? A comparison of in vivo and ex vivo responses to treatment. Med Oncol 2011; 29:2111-26. [PMID: 22086735 DOI: 10.1007/s12032-011-0105-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 10/28/2011] [Indexed: 12/15/2022]
Abstract
Malfunctions in the regulation of apoptosis cause the accumulation of malignant, long-lived B CD19+/CD5+ cells in chronic lymphocytic leukemia (CLL). The primary goal in CLL therapy is to overcome resistance to apoptosis and efficiently trigger programmed cell death in leukemic cells. This study demonstrated that the in vivo responses of malignant cells from CLL patients after administration of purine analogs (cladribine/fludarabine) with cyclophosphamide vary significantly. For comparative purposes, the sensitivity of leukemic cells obtained from the same CLL patients to conventional purine analogs and the selective CDK inhibitor R-roscovitine (ROSC) was determined, with and without the addition of an alkylating agent, prior to the onset of in vivo therapy. The kinetics and rate of spontaneous and drug-induced apoptosis of CLL cells under ex vivo conditions differed significantly between patients, mirroring the variability observed during in vivo treatment. Interestingly, individual patients' leukemic cells were comparably sensitive to the drugs under both conditions. Of the drugs examined, ROSC exerted the highest therapeutic efficacy under ex vivo conditions. Our results indicate that ex vivo testing might be useful for identifying the most potent first-line therapeutic regimen for specific CLL patients and possibly for the design of therapies tailored for individual CLL patients.
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Affiliation(s)
- Jolanta D Żołnierczyk
- Department of Cytobiochemistry, University of Łódz, Pomorska 141/143, 90-236 Łódz, Poland
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Wendtner CM, Hillmen P, Mahadevan D, Bühler A, Uharek L, Coutré S, Frankfurt O, Bloor A, Bosch F, Furman RR, Kimby E, Gribben JG, Gobbi M, Dreisbach L, Hurd DD, Sekeres MA, Ferrajoli A, Shah S, Zhang J, Moutouh-de Parseval L, Hallek M, Heerema NA, Stilgenbauer S, Chanan-Khan AA. Final results of a multicenter phase 1 study of lenalidomide in patients with relapsed or refractory chronic lymphocytic leukemia. Leuk Lymphoma 2011; 53:417-23. [PMID: 21879809 DOI: 10.3109/10428194.2011.618232] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Based on clinical activity in phase 2 studies, lenalidomide was evaluated in a phase 2/3 study in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). Following tumor lysis syndrome (TLS) complications, the protocol was amended to a phase 1 study to identify the maximum tolerated dose-escalation level (MTDEL). Fifty-two heavily pretreated patients, 69% with bulky disease and 48% with high-risk genomic abnormalities, initiated lenalidomide at 2.5 mg/day, with dose escalation until the MTDEL or the maximum assigned dose was attained. Lenalidomide was safely titrated to 20 mg/day; the MTDEL was not reached. Most common grade 3-4 adverse events were neutropenia and thrombocytopenia; TLS was mild and rare. The low starting dose and conservative dose escalation strategy resulted in six partial responders and 30 patients obtaining stable disease. In summary, lenalidomide 2.5 mg/day is a safe starting dose that can be titrated up to 20 mg/day in patients with CLL.
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Affiliation(s)
- Clemens-Martin Wendtner
- Department I of Internal Medicine, Center of Integrated Oncology (CIO), CECAD, University of Cologne, Cologne, Germany.
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Pileckyte R, Jurgutis M, Valceckiene V, Stoskus M, Gineikiene E, Sejoniene J, Degulys A, Zvirblis T, Griskevicius L. Dose-dense high-dose methylprednisolone and rituximab in the treatment of relapsed or refractory high-risk chronic lymphocytic leukemia. Leuk Lymphoma 2011; 52:1055-65. [PMID: 21599591 DOI: 10.3109/10428194.2011.562572] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This study evaluated the efficacy and safety of dose-dense high-dose methylprednisolone (HDMP) plus rituximab (Rtx) in patients with high-risk CLL. Twenty-nine patients with relapsed or progressive CLL with adverse cytogenetics (17p deletion, TP53 mutation, 11q deletion, and/or trisomy 12) and/or progression within 12 months of fludarabine treatment were included. HDMP (1 g/m(2)) was administered daily for 5 days of each treatment course. Rtx was administered on days 1 (375 mg/m(2)) and 5 (500 mg/m(2)) of the first treatment course, on days 1 (500 mg/m(2)) and 5 (500 mg/m(2)) of the second course, and on day 1 (500 mg/m(2)) of courses 3-6. The cycles were repeated every 21 days. The overall response rate (ORR) was 62%, and 28% of patients had stable disease. In 13 patients with 17p deletion/TP53 mutation, ORR was 69%. After 22 months, the median progression-free and overall survivals were 12 and 31 months, respectively. The most frequent toxicity was hyperglycemia, and three deaths occurred in the study. Dose-dense treatment with HDMP and Rtx is an effective therapy with a favorable safety profile in patients with high-risk CLL, including those with 17p deletion/TP53 mutation.
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Affiliation(s)
- Regina Pileckyte
- Department of Hematology, Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santariskiu Clinics, Vilnius, Lithuania.
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Lanasa MC, Davis PH, Datto M, Li Z, Gockerman JP, Moore JO, DeCastro CM, Friedman DR, Diehl LF, Rehder C, Cook H, Daugherty FJ, Matta KMB, Weinberg JB, Rizzieri D. Phase II study of cenersen, an antisense inhibitor of p53, in combination with fludarabine, cyclophosphamide and rituximab for high-risk chronic lymphocytic leukemia. Leuk Lymphoma 2011; 53:218-24. [PMID: 21827374 DOI: 10.3109/10428194.2011.610012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) with deletion or mutation of TP53 have exceedingly poor clinical outcomes. Cenersen, an oligonucleotide targeting TP53, has been shown to abrogate the activity of TP53 gain-of-function mutants and to increase sensitivity of lymphoma cells to cytotoxic chemotherapy in vitro. We combined cenersen with fludarabine, cyclophosphamide and rituximab (FCR) as treatment for patients with high-risk CLL. The purpose of this phase II study was to determine the overall response rate, response duration and toxicity of cenersen administered in combination with FCR. Twenty patients with relapsed or high-risk CLL were evaluated. Nineteen patients were previously treated. The complete response rate was 18%; the overall response rate was 53%. Median progression-free and overall survival was 5.3 and 10.6 months, respectively. The most common serious adverse events were neutropenia and thrombocytopenia. In this single arm phase II study, cenersen combined with FCR yielded clinical responses with acceptable toxicity in patients with high-risk CLL.
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Affiliation(s)
- Mark C Lanasa
- Duke University Medical Center, Durham, NC 27710, USA.
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McClune BL, Defor T, Brunstein C, Vogel RI, Majhail NS, Bachanova V, Burns LJ, Slungaard A, Weisdorf DJ. Reduced intensity allogeneic haematopoietic cell transplantation for chronic lymphocytic leukaemia: related donor and umbilical cord allografting. Br J Haematol 2011; 156:273-5. [PMID: 21923655 DOI: 10.1111/j.1365-2141.2011.08842.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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