1
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Phillips DC, Jin S, Gregory GP, Zhang Q, Xue J, Zhao X, Chen J, Tong Y, Zhang H, Smith M, Tahir SK, Clark RF, Penning TD, Devlin JR, Shortt J, Hsi ED, Albert DH, Konopleva M, Johnstone RW, Leverson JD, Souers AJ. A novel CDK9 inhibitor increases the efficacy of venetoclax (ABT-199) in multiple models of hematologic malignancies. Leukemia 2020; 34:1646-1657. [PMID: 31827241 PMCID: PMC7266741 DOI: 10.1038/s41375-019-0652-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 10/18/2019] [Accepted: 11/13/2019] [Indexed: 01/07/2023]
Abstract
MCL-1 is one of the most frequently amplified genes in cancer, facilitating tumor initiation and maintenance and enabling resistance to anti-tumorigenic agents including the BCL-2 selective inhibitor venetoclax. The expression of MCL-1 is maintained via P-TEFb-mediated transcription, where the kinase CDK9 is a critical component. Consequently, we developed a series of potent small-molecule inhibitors of CDK9, exemplified by the orally active A-1592668, with CDK selectivity profiles that are distinct from related molecules that have been extensively studied clinically. Short-term treatment with A-1592668 rapidly downregulates RNA pol-II (Ser 2) phosphorylation resulting in the loss of MCL-1 protein and apoptosis in MCL-1-dependent hematologic tumor cell lines. This cell death could be attenuated by either inhibiting caspases or overexpressing BCL-2 protein. Synergistic cell killing was also observed between A-1592668 or the related analog A-1467729, and venetoclax in a number of hematologic cell lines and primary NHL patient samples. Importantly, the CDK9 inhibitor plus venetoclax combination was well tolerated in vivo and demonstrated efficacy superior to either agent alone in mouse models of lymphoma and AML. These data indicate that CDK9 inhibitors could be highly efficacious in tumors that depend on MCL-1 for survival or when used in combination with venetoclax in malignancies dependent on MCL-1 and BCL-2.
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Affiliation(s)
- Darren C Phillips
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA.
| | - Sha Jin
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Gareth P Gregory
- Peter MacCallum Cancer Centre, Translational Hematology Program, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- Blood Cancer Therapeutics Laboratory, School of Clinical Sciences at Monash Health, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - Qi Zhang
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - John Xue
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Xiaoxian Zhao
- Department of Laboratory Medicine, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Jun Chen
- TEST, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Yunsong Tong
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Haichao Zhang
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Morey Smith
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Stephen K Tahir
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Rick F Clark
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Thomas D Penning
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Jennifer R Devlin
- Peter MacCallum Cancer Centre, Translational Hematology Program, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Grattan Street, Parkville, VIC, 3052, Australia
| | - Jake Shortt
- Blood Cancer Therapeutics Laboratory, School of Clinical Sciences at Monash Health, Monash University, 246 Clayton Rd, Clayton, VIC, 3168, Australia
| | - Eric D Hsi
- Department of Laboratory Medicine, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Daniel H Albert
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Ricky W Johnstone
- Peter MacCallum Cancer Centre, Translational Hematology Program, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Grattan Street, Parkville, VIC, 3052, Australia
| | - Joel D Leverson
- Oncology-Development, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
| | - Andrew J Souers
- Oncology-Discovery, AbbVie Inc., 1 North Waukegan Road, North Chicago, IL, 60064, USA
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2
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Therapeutic Targeting of the General RNA Polymerase II Transcription Machinery. Int J Mol Sci 2020; 21:ijms21093354. [PMID: 32397434 PMCID: PMC7246882 DOI: 10.3390/ijms21093354] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 12/27/2022] Open
Abstract
Inhibitors targeting the general RNA polymerase II (RNAPII) transcription machinery are candidate therapeutics in cancer and other complex diseases. Here, we review the molecular targets and mechanisms of action of these compounds, framing them within the steps of RNAPII transcription. We discuss the effects of transcription inhibitors in vitro and in cellular models (with an emphasis on cancer), as well as their efficacy in preclinical and clinical studies. We also discuss the rationale for inhibiting broadly acting transcriptional regulators or RNAPII itself in complex diseases.
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3
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Lee C, Huang X, Di Liberto M, Martin P, Chen-Kiang S. Targeting CDK4/6 in mantle cell lymphoma. ACTA ACUST UNITED AC 2020; 4. [PMID: 32783046 DOI: 10.21037/aol.2019.12.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Targeting the cell cycle represents a rational approach to mantle cell lymphoma (MCL) therapy, as aberrant expression of cyclin D1 and dysregulation of CDK4 underlie cell cycle progression and proliferation of MCL cells. Although cell cycle cancer therapy was historically ineffective due to a lack of selective and effective drugs, this landscape changed with the advent of selective and potent small-molecule oral CDK4/6 inhibitors. Here, we review the anti-tumor activities and clinical data of selective CDK4/6 inhibitors in MCL. We summarize the known mechanism of action of palbociclib, the most specific CDK4/6 inhibitor to date, and the strategy to leverage this specificity to reprogram MCL for a deeper and more durable clinical response to partner drugs. We also discuss integrative longitudinal functional genomics as a strategy to discover tumor-intrinsic genomic biomarkers and tumor-immune interactions that potentially contribute to the clinical response to palbociclib in combination therapy for MCL. Understanding the genomic basis for targeting CDK4/6 and the mechanisms of action and resistance in MCL may advance personalized therapy for MCL and shed light on drug resistance in other cancers.
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Affiliation(s)
- Christina Lee
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10065, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Xiangao Huang
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Maurizio Di Liberto
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Peter Martin
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Selina Chen-Kiang
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY 10065, USA.,Program in Immunology and Microbial Pathogenesis, Weill Cornell Medicine, New York, NY 10065, USA
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4
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Bisol Â, de Campos PS, Lamers ML. Flavonoids as anticancer therapies: A systematic review of clinical trials. Phytother Res 2019; 34:568-582. [PMID: 31752046 DOI: 10.1002/ptr.6551] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 09/25/2019] [Accepted: 10/28/2019] [Indexed: 12/17/2022]
Abstract
Flavonoids have been proposed as potential chemotherapeutic agents because they are toxic against cancer cells but not harmful to healthy cells. This systematic review analyzed flavonoid effectiveness in human cancer chemotherapy. Overall, 22 phase II and 1 phase III clinical trials (PubMed, Scopus, and Web of Science) that used flavonoids as a single agent or combined with other therapeutics against hematopoietic/lymphoid or solid cancer published by January 2019 were selected for analysis. Flavopiridol was the most commonly used flavonoid (at a dose of 50-mg/m2 IV) for all tumor types. Aside from the relatively low rate of complete response (CR) or partial response (PR) with any administration protocol, flavonoids showed higher positive outcomes for hematopoietic and lymphoid tissues (140 patients with CR and 88 with PR among 615 patients in 11 trials) than for solid tumors (4 patients with CR and 21 with PR among 525 patients in 12 trials). However, because of the high variety in administration schedule, more studies are needed to further understand how flavonoids can promote positive outcomes for cancer patients.
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Affiliation(s)
- Ângela Bisol
- Basic Research Center in Dentistry, Dentistry School, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Paloma Santos de Campos
- Basic Research Center in Dentistry, Dentistry School, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcelo Lazzaron Lamers
- Basic Research Center in Dentistry, Dentistry School, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Department of Morphological Sciences, Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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5
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Delou JMA, Souza ASO, Souza LCM, Borges HL. Highlights in Resistance Mechanism Pathways for Combination Therapy. Cells 2019; 8:E1013. [PMID: 31480389 PMCID: PMC6770082 DOI: 10.3390/cells8091013] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/15/2019] [Accepted: 08/20/2019] [Indexed: 12/14/2022] Open
Abstract
Combination chemotherapy has been a mainstay in cancer treatment for the last 60 years. Although the mechanisms of action and signaling pathways affected by most treatments with single antineoplastic agents might be relatively well understood, most combinations remain poorly understood. This review presents the most common alterations of signaling pathways in response to cytotoxic and targeted anticancer drug treatments, with a discussion of how the knowledge of signaling pathways might support and orient the development of innovative strategies for anticancer combination therapy. The ultimate goal is to highlight possible strategies of chemotherapy combinations based on the signaling pathways associated with the resistance mechanisms against anticancer drugs to maximize the selective induction of cancer cell death. We consider this review an extensive compilation of updated known information on chemotherapy resistance mechanisms to promote new combination therapies to be to discussed and tested.
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Affiliation(s)
- João M A Delou
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Alana S O Souza
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Leonel C M Souza
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil
| | - Helena L Borges
- Institute of Biomedical Sciences, Federal University of Rio de Janeiro, Rio de Janeiro 21941-902, Brazil.
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6
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Miljkovic MD, Roschewski M, Dunleavy K, Wilson WH. Hybrid dosing of the cyclin-dependent kinase (CDK) inhibitor flavopiridol in relapsed/refractory mantle cell lymphoma and diffuse large B-cell lymphoma. Leuk Lymphoma 2019; 60:3320-3323. [PMID: 31204529 DOI: 10.1080/10428194.2019.1627540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Milos D Miljkovic
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Kieron Dunleavy
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.,Department of Medicine, The George Washington University, Washington, DC, USA
| | - Wyndham H Wilson
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
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7
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Srikumar T, Padmanabhan J. Potential Use of Flavopiridol in Treatment of Chronic Diseases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 929:209-228. [PMID: 27771926 DOI: 10.1007/978-3-319-41342-6_9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This chapter describes the potential use of flavopiridol, a CDK inhibitor with anti-inflammatory and anti-proliferative activities, in the treatment of various chronic diseases. Flavopiridol arrests cell cycle progression in the G1 or G2 phase by inhibiting the kinase activities of CDK1, CDK2, CDK4/6, and CDK7. Additionally, it binds tightly to CDK9, a component of the P-TEFb complex (CDK9/cyclin T), and interferes with RNA polymerase II activation and associated transcription. This in turn inhibits expression of several pro-survival and anti-apoptotic genes, and enhances cytotoxicity in transformed cells or differentiation in growth-arrested cells. Recent studies indicate that flavopiridol elicits anti-inflammatory activity via CDK9 and NFκB-dependent signaling. Overall, these effects of flavopiridol potentiate its ability to overcome aberrant cell cycle activation and/or inflammatory stimuli, which are mediators of various chronic diseases.
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Affiliation(s)
- Thejal Srikumar
- Morsani College of Medicine, University of South Florida, Tampa, Florida, 33612, USA
| | - Jaya Padmanabhan
- Department of Molecular Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, 33612, USA. .,USF Health Byrd Alzheimer's Institute, University of South Florida, 4001 E. Fletcher Ave., Tampa, Florida, 33613, USA.
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8
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Phillips DC, Xiao Y, Lam LT, Litvinovich E, Roberts-Rapp L, Souers AJ, Leverson JD. Loss in MCL-1 function sensitizes non-Hodgkin's lymphoma cell lines to the BCL-2-selective inhibitor venetoclax (ABT-199). Blood Cancer J 2015; 5:e368. [PMID: 26565405 PMCID: PMC4670945 DOI: 10.1038/bcj.2015.88] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 08/05/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023] Open
Abstract
As a population, non-Hodgkin's lymphoma (NHL) cell lines positive for the t(14;18) translocation and/or possessing elevated BCL2 copy number (CN; BCL2(High)) are exquisitely sensitive to navitoclax or the B-cell lymphoma protein-2 (BCL-2)-selective inhibitor venetoclax. Despite this, some BCL2(High) cell lines remain resistant to either agent. Here we show that the MCL-1-specific inhibitor A-1210477 sensitizes these cell lines to navitoclax. Chemical segregation of this synergy with the BCL-2-selective inhibitor venetoclax or BCL-XL-selective inhibitor A-1155463 indicated that MCL-1 and BCL-2 are the two key anti-apoptotic targets for sensitization. Similarly, the CDK inhibitor flavopiridol downregulated MCL-1 expression and synergized with venetoclax in BCL2(High) NHL cell lines to a similar extent as A-1210477. A-1210477 also synergized with navitoclax in the majority of BCL2(Low) NHL cell lines. However, chemical segregation with venetoclax or A-1155463 revealed that synergy was driven by BCL-XL inhibition in this population. Collectively these data emphasize that BCL2 status is predictive of venetoclax potency in NHL not only as a single agent, but also in the adjuvant setting with anti-tumorigenic agents that inhibit MCL-1 function. These studies also potentially identify a patient population (BCL2(Low)) that could benefit from BCL-XL (navitoclax)-driven combination therapy.
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Affiliation(s)
- D C Phillips
- Oncology Discovery, AbbVie Inc., North Chicago, IL, USA
| | - Y Xiao
- Oncology Discovery, AbbVie Inc., North Chicago, IL, USA
| | - L T Lam
- Oncology Discovery, AbbVie Inc., North Chicago, IL, USA
| | | | | | - A J Souers
- Oncology Development, AbbVie Inc., North Chicago, IL, USA
| | - J D Leverson
- Oncology Development, AbbVie Inc., North Chicago, IL, USA
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9
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Maddocks K, Wei L, Rozewski D, Jiang Y, Zhao Y, Adusumilli M, Pierceall WE, Doykin C, Cardone MH, Jones JA, Flynn J, Andritsos LA, Grever MR, Byrd JC, Johnson AJ, Phelps MA, Blum KA. Reduced occurrence of tumor flare with flavopiridol followed by combined flavopiridol and lenalidomide in patients with relapsed chronic lymphocytic leukemia (CLL). Am J Hematol 2015; 90:327-33. [PMID: 25639448 DOI: 10.1002/ajh.23946] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Abstract
Flavopiridol and lenalidomide have activity in refractory CLL without immunosuppression or opportunistic infections seen with other therapies. We hypothesized that flavopiridol treatment could adequately de-bulk disease prior to lenalidomide therapy, decreasing the incidence of tumor flare with higher doses of lenalidomide. In this Phase I study, the maximum tolerated dose was not reached with treatment consisting of flavopiridol 30 mg m(-2) intravenous bolus (IVB) + 30 mg m(-2) continuous intravenous infusion (CIVI) cycle (C) 1 day (D) 1 and 30 mg m(-2) IVB + 50 mg m(-2) CIVI C1 D8,15 and C2-8 D3,10,17 with lenalidomide 15 mg orally daily C2-8 D1-21. There was no unexpected toxicity seen, including no increased tumor lysis, tumor flare (even at higher doses of lenalidomide) or opportunistic infection. Significant clinical activity was demonstrated, with a 51% response rate in this group of heavily pretreated patients. Biomarker testing confirmed association of mitochondrial priming of the BH3 only peptide Puma with response.
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Affiliation(s)
- Kami Maddocks
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Lai Wei
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Darlene Rozewski
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Yao Jiang
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Yuan Zhao
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Mikhil Adusumilli
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - William E. Pierceall
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Camille Doykin
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Michael H. Cardone
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Jeffrey A. Jones
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Joseph Flynn
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Leslie A. Andritsos
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Michael R. Grever
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - John C. Byrd
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Amy J. Johnson
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Mitch A. Phelps
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
| | - Kristie A Blum
- Division of Hematology; Department of Internal Medicine; The Ohio State University, Comprehensive Cancer Center, The Ohio State University, College of Pharmacy, The Ohio State University; Ohio
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10
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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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11
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Njue A, Colosia A, Trask PC, Olivares R, Khan S, Abbe A, Police R, Wang J, Ruiz-Soto R, Kaye JA, Awan F. Clinical efficacy and safety in relapsed/refractory mantle cell lymphoma: a systematic literature review. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 15:1-12.e7. [PMID: 25052050 DOI: 10.1016/j.clml.2014.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/11/2014] [Accepted: 03/17/2014] [Indexed: 12/14/2022]
Abstract
A systematic literature review was performed to collect and review information on the clinical efficacy and safety of treatments for relapsed/refractory (R/R) mantle cell lymphoma (MCL), with a meta-analysis, if possible. PubMed, Embase, and the Cochrane Library were searched for studies published in English from January 1, 1997, to August 2, 2012. Conference proceedings, bibliographic reference lists of included articles, recent reviews, and ClinicalTrials.gov were searched for phase II to IV studies displaying results. Studies were included if they reported on patients with R/R MCL who were ineligible to receive high-dose chemotherapy with stem cell transplant. Studies of patients with several non-Hodgkin lymphoma subtypes were only included if they reported MCL outcomes separately. We identified 59 studies in R/R MCL. Forty distinct treatment regimens were evaluated. Thirty studies included more than 15 patients with R/R MCL. Six studies were comparative (including 5 randomized controlled trials [RCTs]); 53 were single-arm. There were no common treatments among the RCTs; therefore, a meta-analysis was not feasible. Thirty-one of 59 studies reported baseline data for patients with R/R MCL. Of the 30 studies with > 15 patients with R/R MCL, 30 reported overall response rate data, 14 reported progression-free survival (PFS), and 12 reported overall survival (OS). The small number of RCTs in R/R MCL precludes identifying an optimal treatment. Small sample sizes, infrequent reporting of OS and PFS, and limited information on patient characteristics made a comparison of results difficult. High-quality comparative studies of novel therapies that have the potential to demonstrate OS advantages in R/R MCL are needed.
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Affiliation(s)
- Annete Njue
- RTI Health Solutions, The Pavillion, Towers Business Park, Manchester, United Kingdom.
| | - Ann Colosia
- RTI Health Solutions, Research Triangle Park, NC
| | - Peter C Trask
- Global Evidence and Value Development, Sanofi, Cambridge, MA
| | - Robert Olivares
- Global Evidence and Value Development, Sanofi, Chilly-Mazarin, France
| | - Shahnaz Khan
- RTI Health Solutions, The Pavillion, Towers Business Park, Manchester, United Kingdom
| | - Adeline Abbe
- Global Evidence and Value Development, Sanofi, Chilly-Mazarin, France
| | | | - Jianmin Wang
- RTI Health Solutions, The Pavillion, Towers Business Park, Manchester, United Kingdom
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12
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Jones JA, Rupert AS, Poi M, Phelps MA, Andritsos L, Baiocchi R, Benson DM, Blum KA, Christian B, Flynn J, Penza S, Porcu P, Grever MR, Byrd JC. Flavopiridol can be safely administered using a pharmacologically derived schedule and demonstrates activity in relapsed and refractory non-Hodgkin's lymphoma. Am J Hematol 2014; 89:19-24. [PMID: 23959599 PMCID: PMC4150545 DOI: 10.1002/ajh.23568] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Revised: 07/07/2013] [Accepted: 08/06/2013] [Indexed: 01/14/2023]
Abstract
Flavopiridol is a broad cyclin-dependent kinase inhibitor (CDKI) that induces apoptosis of malignant lymphocytes in vitro and in murine lymphoma models. We conducted a Phase I dose-escalation study to determine the maximum tolerated dose (MTD) for single-agent flavopiridol administered on a pharmacokinetically derived hybrid dosing schedule to patients with relapsed and refractory non-Hodgkin's lymphoma. Dose was escalated independently in one of four cohorts: indolent B-cell (Cohort 1), mantle cell (Cohort 2), intermediate-grade B-cell including transformed lymphoma (Cohort 3), and T-/NK-cell excluding primary cutaneous disease (Cohort 4). Forty-six patients were accrued. Grade 3 or 4 leukopenia was observed in the majority of patients (60%), but infection was infrequent. Common nonhematologic toxicities included diarrhea and fatigue. Biochemical tumor lysis was observed in only two patients, and no patients required hemodialysis for its management. Dose escalation was completed in two cohorts (indolent and aggressive B-cell). Dose-limiting toxicities were not observed, and the MTD was not reached in either cohort at the highest dose tested (50 mg/m(2) bolus + 50 mg/m(2) continuous infusion weekly for 4 consecutive weeks of a 6-week cycle). Clinical benefit was observed in 26% of 43 patients evaluable for response, including 14% with partial responses (two mantle cells, three indolent B-cells, and one diffuse large B-cell). The single-agent activity of this first-generation CDKI suggests that other agents in this class merit further study in lymphoid malignancies, both alone and in combination.
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Affiliation(s)
- Jeffrey A. Jones
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Amy S. Rupert
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Ming Poi
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210
| | - Mitch A. Phelps
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210
| | - Leslie Andritsos
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Robert Baiocchi
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Don M. Benson
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Kristie A. Blum
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Beth Christian
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Joseph Flynn
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Sam Penza
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Pierluigi Porcu
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - Michael R. Grever
- Division of Hematology, The Ohio State University, Columbus, OH 43210
| | - John C. Byrd
- Division of Hematology, The Ohio State University, Columbus, OH 43210
- Division of Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH 43210
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Abstract
Abstract As the rational application of targeted therapies in cancer supplants traditional cytotoxic chemotherapy, there is an ever-greater need for a thorough understanding of the complex machinery of the cell and an application of this knowledge to the development of novel therapeutics and combinations of agents. Here, we review the current state of knowledge of the class of targeted agents known as cyclin-dependent kinase (CDK) inhibitors, with a focus on chronic lymphocytic leukemia (CLL). Flavopiridol (alvocidib) is the best studied of the CDK inhibitors, producing a dramatic cytotoxic effect in vitro and in vivo, with the principal limiting factor of acute tumor lysis. Unfortunately, flavopiridol has a narrow therapeutic window and is relatively non-selective with several off-target (i.e. non-CDK) effects, which prompted development of the second-generation CDK inhibitor dinaciclib. Dinaciclib appears to be both more potent and selective than flavopiridol, with at least an order of magnitude greater therapeutic index, and is currently in phase III clinical trials. In additional to flavopiridol and dinaciclib, we also review the current status of other members of this class, and provide commentary as to the future direction of combination therapy including CDK inhibitors.
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Yap TA, Molife LR, Blagden SP, de Bono S. Targeting cell cycle kinases and kinesins in anticancer drug development. Expert Opin Drug Discov 2013; 2:539-60. [PMID: 23484760 DOI: 10.1517/17460441.2.4.539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The cell cycle is regulated by kinases such as the cyclin-dependent kinases (CDKs) and non-CDKs, which include Aurora and polo-like kinases, as well as checkpoint proteins. Mitotic kinesins are involved in the establishment of the mitotic spindle formation and function, and also play a role in cell cycle control. The disruption of the cell cycle is a hallmark of malignancy. Genetic or epigenetic events result in the upregulation of these kinases and mitotic kinesins in a myriad of tumour types, suggesting that their inhibition could result in preferential targeting of malignant cells. Such findings make the development of these inhibitors a rational and attractive new area for cancer therapeutics. Although challenges of potency and non-specificity have hampered their progress through the clinic, several novel compounds are presently in various phases of clinical trial evaluation.
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Affiliation(s)
- Timothy A Yap
- Drug Development Unit, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, Surrey, SM2 5PT, UK.
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15
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Ji J, Mould DR, Blum KA, Ruppert AS, Poi M, Zhao Y, Johnson AJ, Byrd JC, Grever MR, Phelps MA. A pharmacokinetic/pharmacodynamic model of tumor lysis syndrome in chronic lymphocytic leukemia patients treated with flavopiridol. Clin Cancer Res 2013; 19:1269-80. [PMID: 23300276 DOI: 10.1158/1078-0432.ccr-12-1092] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Flavopiridol, the first clinically evaluated cyclin-dependent kinase inhibitor, shows activity in patients with refractory chronic lymphocytic leukemia, but prevalent and unpredictable tumor lysis syndrome (TLS) presents a major barrier to its broad clinical use. The purpose of this study was to investigate the relationships between pretreatment risk factors, drug pharmacokinetics, and TLS. EXPERIMENTAL DESIGN A population pharmacokinetic/pharmacodynamic model linking drug exposure and TLS was developed. Plasma data of flavopiridol and its glucuronide metabolite (flavo-G) were obtained from 111 patients treated in early-phase trials with frequent sampling following initial and/or escalated doses. TLS grading was modeled with logistic regression as a pharmacodynamic endpoint. Demographics, baseline disease status, and blood chemistry variables were evaluated as covariates. RESULTS Gender was the most significant pharmacokinetic covariate, with females displaying higher flavo-G exposure than males. Glucuronide metabolite exposure was predictive of TLS occurrence, and bulky lymphadenopathy was identified as a significant covariate on TLS probability. The estimated probability of TLS occurrence in patients with baseline bulky lymphadenopathy less than 10 cm or 10 cm or more during the first 2 treatments was 0.111 (SE% 13.0%) and 0.265 (SE% 17.9%), respectively, when flavo-G area under the plasma concentration versus time curve was at its median value in whole-patient group. CONCLUSIONS This is the first population pharmacokinetic/pharmacodynamic model of TLS. Further work is needed to explore potential mechanisms and to determine whether the associations between TLS, gender, and glucuronide metabolites are relevant in patients with chronic lymphocytic leukemia treated with other cyclin-dependent kinase inhibitors.
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Affiliation(s)
- Jia Ji
- The Comprehensive Cancer Center, College of Pharmacy, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio 43210, USA
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Deng C, Lee S, O'Connor OA. New Strategies in the Treatment of Mantle Cell Lymphoma. Clin Cancer Res 2012; 18:3499-508. [DOI: 10.1158/1078-0432.ccr-11-3152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Holkova B, Perkins EB, Ramakrishnan V, Tombes MB, Shrader E, Talreja N, Wellons MD, Hogan KT, Roodman GD, Coppola D, Kang L, Dawson J, Stuart RK, Peer C, Figg WD, Kolla S, Doyle A, Wright J, Sullivan DM, Roberts JD, Grant S. Phase I trial of bortezomib (PS-341; NSC 681239) and alvocidib (flavopiridol; NSC 649890) in patients with recurrent or refractory B-cell neoplasms. Clin Cancer Res 2011; 17:3388-97. [PMID: 21447728 DOI: 10.1158/1078-0432.ccr-10-2876] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE A phase I study was conducted to determine the dose-limiting toxicities (DLT) and maximum tolerated dose (MTD) for the combination of bortezomib and alvocidib in patients with B-cell malignancies (multiple myeloma, indolent lymphoma, and mantle cell lymphoma). EXPERIMENTAL DESIGN Patients received bortezomib by intravenous push on days 1, 4, 8, and 11. Patients also received alvocidib on days 1 and 8 by 30-minute bolus infusion followed by a 4-hour continuous infusion. Treatment was on a 21-day cycle, with indefinite continuation for patients experiencing responses or stable disease. Dose escalation employed a standard 3 + 3 design until the MTD was identified on the basis of DLTs. Pharmacokinetic studies and pharmacodynamic studies were conducted. RESULTS Sixteen patients were treated. The MTD was established as 1.3 mg/m(2) for bortezomib and 30 mg/m(2) for alvocidib (both the 30-minute bolus and 4-hour infusions). Common hematologic toxicities included leukopenia, lymphopenia, neutropenia, and thrombocytopenia. Common nonhematologic toxicities included fatigue and febrile neutropenia. DLTs included fatigue, febrile neutropenia, and elevated aspartate aminotransferase (AST) levels. Two complete responses (CR; 12%) and five partial responses (PR; 31%) were observed at the MTD (overall response rate = 44%). Pharmacokinetic results were typical for alvocidib and pharmacodynamic studies yielded variable results. CONCLUSIONS The combination of bortezomib and alvocidib is tolerable and an MTD has been established for the tested schedule. The regimen appears active in patients with relapsed and/or refractory multiple myeloma or non-Hodgkin's lymphoma, justifying phase II studies to determine the activity of this regimen more definitively.
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Affiliation(s)
- Beata Holkova
- Massey Cancer Center and the Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia 23298, USA
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Flavopiridol pharmacogenetics: clinical and functional evidence for the role of SLCO1B1/OATP1B1 in flavopiridol disposition. PLoS One 2010; 5:e13792. [PMID: 21072184 PMCID: PMC2967470 DOI: 10.1371/journal.pone.0013792] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Accepted: 09/27/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Flavopiridol is a cyclin-dependent kinase inhibitor in phase II clinical development for treatment of various forms of cancer. When administered with a pharmacokinetically (PK)-directed dosing schedule, flavopiridol exhibited striking activity in patients with refractory chronic lymphocytic leukemia. This study aimed to evaluate pharmacogenetic factors associated with inter-individual variability in pharmacokinetics and outcomes associated with flavopiridol therapy. METHODOLOGY/PRINCIPAL FINDINGS Thirty-five patients who received single-agent flavopiridol via the PK-directed schedule were genotyped for 189 polymorphisms in genes encoding 56 drug metabolizing enzymes and transporters. Genotypes were evaluated in univariate and multivariate analyses as covariates in a population PK model. Transport of flavopiridol and its glucuronide metabolite was evaluated in uptake assays in HEK-293 and MDCK-II cells transiently transfected with SLCO1B1. Polymorphisms in ABCC2, ABCG2, UGT1A1, UGT1A9, and SLCO1B1 were found to significantly correlate with flavopiridol PK in univariate analysis. Transport assay results indicated both flavopiridol and flavopiridol-glucuronide are substrates of the SLCO1B1/OATP1B1 transporter. Covariates incorporated into the final population PK model included bilirubin, SLCO1B1 rs11045819 and ABCC2 rs8187710. Associations were also observed between genotype and response. To validate these findings, a second set of data with 51 patients was evaluated, and overall trends for associations between PK and PGx were found to be consistent. CONCLUSIONS/SIGNIFICANCE Polymorphisms in transport genes were found to be associated with flavopiridol disposition and outcomes. Observed clinical associations with SLCO1B1 were functionally validated indicating for the first time its relevance as a transporter of flavopiridol and its glucuronide metabolite. A second 51-patient dataset indicated similar trends between genotype in the SLCO1B1 and other candidate genes, thus providing support for these findings. Further study in larger patient populations will be necessary to fully characterize and validate the clinical impact of polymorphisms in SLCO1B1 and other transporter and metabolizing enzyme genes on outcomes from flavopiridol therapy.
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A dose-finding, pharmacokinetic and pharmacodynamic study of a novel schedule of flavopiridol in patients with advanced solid tumors. Invest New Drugs 2010; 30:629-38. [PMID: 20938713 DOI: 10.1007/s10637-010-9563-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 10/03/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Based on the promising activity and tolerability of flavopiridol administered with a pharmacokinetically-derived dosing schedule in chronic lymphocytic leukemia (CLL), we conducted a phase I study using this schedule in patients with advanced solid tumors. EXPERIMENTAL DESIGN Flavopiridol was given IV as a 30-min loading dose followed by a 4-hr infusion weekly for 4 weeks repeated every 6 weeks. Dose-escalation was in cohorts of three patients using the standard 3+3 phase I study design. Blood samples were obtained for pharmacokinetic and pharmacodynamic studies. RESULTS Thirty-four eligible patients with advanced solid tumors received a total of 208 doses (median 7, range 1-24). Total doses ranged from 40 to 105 mg/m(2). The primary dose limiting toxicity was cytokine release syndrome (CKRS). No antitumor responses were observed. The mean peak plasma concentration across all doses was 1.65 ± 0.86 μM. Area under the concentration-versus-time curve ([Formula: see text]) ranged from 4.31 to 32.2 μM[Symbol: see text]hr with an overall mean of 13.6 ± 7.0 μM[Symbol: see text]hr. Plasma flavopiridol concentrations and AUC increased proportionally with dose. There was no correlation between cytokine levels and clinical outcomes. CONCLUSIONS The maximum-tolerated dose of flavopiridol is 20 mg/m(2) bolus followed by 20 mg/m(2) infusion over 4 h given weekly for 4 weeks on a 6-week cycle in patients with advanced solid tumors. Flavopiridol PK was notably different, and there was a higher frequency of CKRS, despite prophylactic steroids, seen in this patient group compared to previous studies with CLL using a similar dosing schedule.
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20
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Christian BA, Grever MR, Byrd JC, Lin TS. Flavopiridol in chronic lymphocytic leukemia: a concise review. ACTA ACUST UNITED AC 2010; 9 Suppl 3:S179-85. [PMID: 19778838 DOI: 10.3816/clm.2009.s.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) with high-risk cytogenetic features such as del(17p13) have limited treatment options and decreased overall survival. Dysfunction of p53 leads to resistance to fludarabine-based therapies. Cyclin-dependent kinase inhibitors (CDKi) are a novel class of agents that induce apoptosis in CLL cells independent of p53 mutational status. The synthetic flavone flavopiridol demonstrated promising in vitro activity in CLL. In initial phase I studies using a continuous infusion dosing schedule in a variety of malignancies, no clinical activity was observed. Detailed pharmacokinetic modeling led to the development of a novel dosing schedule designed to achieve target drug concentrations in vivo. In phase I testing, this dosing schedule resulted in acute tumor lysis syndrome (TLS) as the dose-limiting toxicity. With the implementation of a standardized protocol to prevent severe TLS, flavopiridol was administered safely, and responses were observed in heavily pretreated, fludarabine-refractory patients, cytogenetically high-risk patients, and patients with bulky lymphadenopathy. In a pharmacokinetic analysis, flavopiridol area under the plasma concentration-time curve (AUC) correlated with clinical response and cytokine release syndrome. Phase II studies are under way with encouraging preliminary results. Flavopiridol is currently under active investigation in combination with other agents and as a means to eradicate minimal residual disease in patients following cytoreductive chemotherapy. Several other investigational CDKi in preclinical and early clinical development are briefly discussed in this review.
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Affiliation(s)
- Beth A Christian
- Division of Hematology-Oncology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio 43210, USA.
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22
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Lin TS, Ruppert AS, Johnson AJ, Fischer B, Heerema NA, Andritsos LA, Blum KA, Flynn JM, Jones JA, Hu W, Moran ME, Mitchell SM, Smith LL, Wagner AJ, Raymond CA, Schaaf LJ, Phelps MA, Villalona-Calero MA, Grever MR, Byrd JC. Phase II study of flavopiridol in relapsed chronic lymphocytic leukemia demonstrating high response rates in genetically high-risk disease. J Clin Oncol 2009; 27:6012-8. [PMID: 19826119 PMCID: PMC2793044 DOI: 10.1200/jco.2009.22.6944] [Citation(s) in RCA: 184] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 06/22/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with chronic lymphocytic leukemia (CLL) with high-risk genomic features achieve poor outcomes with traditional therapies. A phase I study of a pharmacokinetically derived schedule of flavopiridol suggested promising activity in CLL, irrespective of high-risk features. Given the relevance of these findings to treating genetically high-risk CLL, a prospective confirmatory study was initiated. PATIENTS AND METHODS Patients with relapsed CLL were treated with single-agent flavopiridol, with subsequent addition of dexamethasone to suppress cytokine release syndrome (CRS). High-risk genomic features were prospectively assessed for response to therapy. RESULTS Sixty-four patients were enrolled. Median age was 60 years, median number of prior therapies was four, and all patients had received prior purine analog therapy. If patients tolerated treatment during week 1, dose escalation occurred during week 2. Dose escalation did not occur in four patients, as a result of severe tumor lysis syndrome; three of these patients required hemodialysis. Thirty-four patients (53%) achieved response, including 30 partial responses (PRs; 47%), three nodular PRs (5%), and one complete response (1.6%). A majority of high-risk patients responded; 12 (57%) of 21 patients with del(17p13.1) and 14 (50%) of 28 patients with del(11q22.3) responded irrespective of lymph node size. Median progression-free survival among responders was 10 to 12 months across all cytogenetic risk groups. Reducing the number of weekly treatments per cycle from four to three and adding prophylactic dexamethasone, which abrogated interleukin-6 release and CRS (P < or = .01), resulted in improved tolerability and treatment delivery. CONCLUSION Flavopiridol achieves significant clinical activity in patients with relapsed CLL, including those with high-risk genomic features and bulky lymphadenopathy. Subsequent clinical trials should use the amended treatment schedule developed herein and prophylactic corticosteroids.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 11
- Chromosomes, Human, Pair 17
- Dexamethasone/administration & dosage
- Disease-Free Survival
- Female
- Flavonoids/administration & dosage
- Flavonoids/adverse effects
- Gene Expression Regulation, Leukemic
- Genetic Predisposition to Disease
- Humans
- Kaplan-Meier Estimate
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Logistic Models
- Male
- Middle Aged
- Piperidines/administration & dosage
- Piperidines/adverse effects
- Prospective Studies
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Recurrence
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
- Tumor Lysis Syndrome/etiology
- Tumor Lysis Syndrome/prevention & control
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Affiliation(s)
- Thomas S. Lin
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Amy S. Ruppert
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Amy J. Johnson
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Beth Fischer
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Nyla A. Heerema
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Leslie A. Andritsos
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Kristie A. Blum
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Joseph M. Flynn
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Jeffrey A. Jones
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Weihong Hu
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Mollie E. Moran
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Sarah M. Mitchell
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Lisa L. Smith
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Amy J. Wagner
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Chelsey A. Raymond
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Larry J. Schaaf
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Mitch A. Phelps
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Miguel A. Villalona-Calero
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - Michael R. Grever
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
| | - John C. Byrd
- From the Division of Hematology and Oncology; Center for Biostatistics; Department of Pathology; and Divisions of Pharmaceutics and Medicinal Chemistry, College of Pharmacy, The Ohio State University, Columbus, OH
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Yang X, Zhao X, Phelps MA, Piao L, Rozewski DM, Liu Q, Lee LJ, Marcucci G, Grever MR, Byrd JC, Dalton JT, Lee RJ. A novel liposomal formulation of flavopiridol. Int J Pharm 2009; 365:170-4. [PMID: 18778761 PMCID: PMC3035394 DOI: 10.1016/j.ijpharm.2008.08.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 08/05/2008] [Accepted: 08/13/2008] [Indexed: 11/23/2022]
Abstract
Flavopiridol has shown promising activities in hematologic and solid tumor models, as well as in clinical trials in chronic lymphocytic leukemia patients. Flavopiridol has relatively low solubility and high plasma protein-binding. To address these issues and to provide an alternative strategy to achieve clinical efficacy, we encapsulated flavopiridol into a liposomal carrier and characterized its physicochemical and pharmacokinetic properties. The liposomes, comprising hydrogenated soy phosphatidylcholine (HSPC), cholesterol and poly (ethylene glycol) 2000-distearoyl phosphatidylethanolamine (PEG-DSPE), were prepared by polycarbonate membrane extrusion and then loaded with flavopiridol by a pH-gradient driven remote loading procedure. The liposomes had a mean diameter of 120.7 nm and a flavopiridol entrapment efficiency of 70.4%. Pharmacokinetic study in mice after i.v. bolus injection showed that the liposomal flavopiridol had an increased elimination phase half-life (T((1/2)beta), 339.7 min vs. 57.0 min), decreased clearance (CL, 0.012 L/min vs. 0.036 L/min), and increased area under the plasma concentration-time curve (AUC, 10.8 min micromol/L vs. 3.4 min micromol/L) compared to the free drug. This indicates a significant and potentially beneficial change in flavopiridol pharmacokinetics for the liposomal formulation. Further preclinical studies are warranted to define the toxicity and therapeutic efficacy of this novel formulation.
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Affiliation(s)
- Xiaojuan Yang
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- NSF Nanoscale Science and Engineering Center (NSEC), The Ohio State University, Columbus, OH 43210, USA
| | - Xiaobin Zhao
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Mitch A. Phelps
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Longzhu Piao
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
| | - Darlene M. Rozewski
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Qing Liu
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - L. James Lee
- NSF Nanoscale Science and Engineering Center (NSEC), The Ohio State University, Columbus, OH 43210, USA
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH 43210, USA
| | - Guido Marcucci
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
- Comprehensive Cancer Center (CCC), The Ohio State University, Columbus, OH 43210, USA
| | - Michael R. Grever
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
- Comprehensive Cancer Center (CCC), The Ohio State University, Columbus, OH 43210, USA
| | - John C. Byrd
- Division of Hematology and Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
- Comprehensive Cancer Center (CCC), The Ohio State University, Columbus, OH 43210, USA
| | - James T. Dalton
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- Comprehensive Cancer Center (CCC), The Ohio State University, Columbus, OH 43210, USA
| | - Robert J. Lee
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, USA
- NSF Nanoscale Science and Engineering Center (NSEC), The Ohio State University, Columbus, OH 43210, USA
- Comprehensive Cancer Center (CCC), The Ohio State University, Columbus, OH 43210, USA
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24
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Lin TS. Novel agents in chronic lymphocytic leukemia: efficacy and tolerability of new therapies. ACTA ACUST UNITED AC 2008; 8 Suppl 4:S137-43. [PMID: 18952544 DOI: 10.3816/clm.2008.s.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Alkylating agents and purine analogues have been the mainstays of therapy for chronic lymphocytic leukemia (CLL) for decades. The past decade witnessed the general clinical use of monoclonal antibodies such as rituximab and alemtuzumab, both as single agents and in combination regimens with cytotoxic drugs, for previously untreated and relapsed CLL. First-line chemoimmunotherapy regimens combining rituximab and purine analogues have greatly improved initial response rates and progression-free survival. Despite these advances in first-line therapy, patients with CLL invariably experience relapse and often acquire high-risk chromosomal abnormalities, such as del(11q22) and del(17p13), which result in resistance to current therapies. Patients who are refractory to fludarabine-based therapy have a median survival of <1 year. Therefore, new agents with novel mechanisms of action are needed for the treatment of patients with relapsed CLL, particularly for patients with high-risk genetic features. Recent clinical studies have examined the tolerability and efficacy of several novel agents in relapsed CLL: (1) the alkylator bendamustine, (2) the cyclin-dependent kinase inhibitor flavopiridol, (3) the immunomodulating drug lenalidomide, (4) the bcl-2 antisense oligonucleotide oblimersen, and (5) the Bcl-2 small-molecule inhibitor obatoclax. While these agents have demonstrated exciting clinical activity against genetically high-risk CLL, they have also induced toxicities that have not been commonly observed with previous CLL therapies. The most notable toxicities have been tumor lysis syndrome and tumor flare, which are potentially serious or even fatal complications of these new therapies. Thus, further studies are needed to define these agents' biologic mechanism(s) of action, clinical activity, and safety.
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Affiliation(s)
- Thomas S Lin
- Division of Hematology and Oncology, The Ohio State University, Columbus, OH 43210, USA.
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Clinical response and pharmacokinetics from a phase 1 study of an active dosing schedule of flavopiridol in relapsed chronic lymphocytic leukemia. Blood 2008; 113:2637-45. [PMID: 18981292 DOI: 10.1182/blood-2008-07-168583] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We previously reported interim results of a phase 1 trial in patients with chronic lymphocytic leukemia (CLL) whereby flavopiridol was administered intravenously as a 30-minute bolus followed by 4-hour infusion. We now report full pharmacokinetic (PK) data, correlations of PK with clinical outcomes, and final response and progression-free survival (PFS). Twenty-one (40%) of 52 patients with relapsed CLL achieved a partial response (PR) with a median PFS of 12 months. Responders included 17 (40%) of 43 fludarabine refractory patients, 7 (39%) of 18 patients with del(17p13), and 14 (74%) of 19 patients with del(11q22). Six responders received repeat therapy at relapse, and 5 responded again with a second median PFS of 10 months. Noncompartmental analysis and nonlinear mixed effects modeling was used to estimate PK parameters and evaluate covariates. Two-compartment population parameter estimates were 31.4 L/h, 65.8 L, 8.49 L/h, and 157 L for CL, V1, Q, and V2, respectively. Flavopiridol area under the plasma concentration-time curve (AUC) correlated with clinical response and cytokine release syndrome, and glucuronide metabolite AUC correlated with tumor lysis syndrome. These composite results confirm high activity of this pharmacokinetically derived schedule in relapsed, genetically high-risk CLL. Furthermore, PK describes some, but not all, variability in response and toxicity.
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Abstract
PURPOSE OF REVIEW Mantle cell lymphoma is characterized by dysregulation of cyclin D1, but this is not sufficient for lymphoma development. It is a difficult disease to treat, being incurable with standard chemotherapy and having a median survival of approximately 5 years. The purpose of this review is to update recent advances in mantle cell lymphoma biology with prognostic and potentially therapeutic implications, and mantle cell lymphoma treatment approaches and new agents. RECENT FINDINGS Genetic alterations that cooperate with cyclin D1 have been described that alter proliferation, in particular p27Kip and p16INK4, or apoptosis. Biological factors such as high-proliferation signature defined by gene expression profiles, loss of p27 and presence of mutant p53 confer poor prognosis. Proliferative rate also predicts patient outcome. Clinical criteria such as the international prognostic index, follicular lymphoma international prognostic index or a formula using age, performance status, white blood cell count and lactate dehydrogenase, separate prognostic groups. Not all patients require therapy at diagnosis. Although the best reported results have been with rituximab-hyperfractionated cyclophosphamide-vincristine-doxorubicin-dexamethasone-methotrexate/cytarabine, a cooperative group study of this regimen appears not quite as successful. Consolidation of remission after rituximab-cyclophosphamide-doxorubicin-vincristine-prednisone with high-dose therapy/stem-cell support prolongs remission and consolidation with radioimmunotherapy shows promise. Intensifying induction by alternating intensified rituximab-cyclophosphamide-doxorubicin-vincristine-prednisone with rituximab and high-dose cytarabine, followed by high-dose therapy appears quite promising. Novel agents active in relapsed disease include bortezomib, mammalian target of rapamycin inhibitors, immunomodulatory agents, antibodies and cyclin pathway-directed agents such as flavopiridol and cyclin-dependent kinase inhibitors. SUMMARY New insights into mantle cell lymphoma biology may lead to targeted therapy. Meanwhile, combinations of existing therapeutic approaches seem to have improved outcomes.
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Phelps MA, Rozewski DM, Johnston JS, Farley KL, Albanese KA, Byrd JC, Lin TS, Grever MR, Dalton JT. Development and validation of a sensitive liquid chromatography/mass spectrometry method for quantitation of flavopiridol in plasma enables accurate estimation of pharmacokinetic parameters with a clinically active dosing schedule. J Chromatogr B Analyt Technol Biomed Life Sci 2008; 868:110-5. [PMID: 18490204 DOI: 10.1016/j.jchromb.2008.04.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2008] [Revised: 04/14/2008] [Accepted: 04/16/2008] [Indexed: 11/26/2022]
Abstract
A high-performance liquid chromatographic assay with tandem mass spectrometric detection was developed and validated for quantitation of the broad spectrum kinase inhibitor, flavopiridol, in human plasma. Sample preparation conditions included liquid-liquid extraction in acetonitrile (ACN), drying, and reconstitution in 20/80 water/ACN. Flavopiridol and the internal standard (IS), genistein, were separated by reversed phase chromatography using a C-18 column and a gradient of water with 25 mM ammonium formate and ACN. Electrospray ionization and detection of flavopiridol and genistein were accomplished with single reaction monitoring of m/z 402.09>341.02 and 271.09>152.90, respectively in positive-ion mode [M+H](+) on a triple quadrupole mass spectrometer. Recovery was greater than 90% throughout the linear range of 3-1000 nM. Replicate sample analysis indicated within- and between-run accuracy and precision to be less than 13% throughout the linear range. This method has the lowest lower limit of quantitation (LLOQ) reported to date for flavopiridol, and it allows for more accurate determination of terminal phase concentrations and improved pharmacokinetic parameter estimation in patients receiving an active dosing schedule of flavopiridol.
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Affiliation(s)
- Mitch A Phelps
- Comprehensive Cancer Center, College of Pharmacy, The Ohio State University, Columbus, OH, USA
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Abstract
Mantle cell lymphoma (MCL) represents 6% of non-Hodgkin lymphomas, but is one of the most active fields of clinical investigation. Unfortunately, there is still no standard or curative therapy in MCL. Front-line therapy appears to benefit from intensification either through high-dose therapy with stem cell transplant consolidation or dose-intense chemotherapy with hyperfractionated cyclophosphamide, vincristine, adriamycin/doxorubicin and dexamethasone/rituximab. Most patients still relapse and a multitude of novel agents are currently being tested in this setting, including proteasome inhibitors with bortezomib (the first of its class and the first US FDA-approved drug for MCL), mTOR inhibitors, Bcl-2 inhibitors, antiangiogenesis agents and histone deacetylase inhibitors among others. An obvious effort is needed to enroll patients on clinical trials, the design of which might benefit from pharmacogenomics and a better understanding of MCL biology and its diversity.
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Affiliation(s)
- K Stephen Suh
- Jurist Research Center, 30 Prospect Avenue, Hackensack NJ 07601, USA
| | - Andre Goy
- HUMC Cancer Center, 20 Prospect Avenue, Hackensack NJ 07601, USA
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Lin TS, Byrd JC. Chronic Lymphocytic Leukemia and Related Chronic Leukemias. Oncology 2007. [DOI: 10.1007/0-387-31056-8_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Christian BA, Grever MR, Byrd JC, Lin TS. Flavopiridol in the treatment of chronic lymphocytic leukemia. Curr Opin Oncol 2007; 19:573-8. [PMID: 17906454 DOI: 10.1097/cco.0b013e3282efb9da] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The synthetic flavone flavopiridol induces apoptosis of chronic lymphocytic leukemia cells in vitro; however, initial studies administering flavopiridol by a 24- to 72-h continuous intravenous infusion demonstrated no clinical activity. This review focuses on a novel dosing regimen that has achieved significant clinical activity in relapsed, poor-risk chronic lymphocytic leukemia. RECENT FINDINGS Binding to human plasma proteins reduces free flavopiridol concentration and makes continuous intravenous infusion dosing ineffective. Pharmacokinetic modeling indicated that administering flavopiridol by a 30-min intravenous bolus followed by a 4-h continuous intravenous infusion would achieve serum concentrations necessary to induce in-vivo apoptosis. Our institution conducted a phase I study in relapsed chronic lymphocytic leukemia. Dose-limiting toxicity was acute tumor lysis syndrome resulting in fatal hyperkalemia. Careful monitoring and aggressive intervention for hyperkalemia, including hemodialysis if necessary, allowed flavopiridol to be given safely. Nineteen of 42 patients responded (45%), including five of 12 patients (42%) with del(17p13) and 13 of 18 patients (72%) with del(11q22). SUMMARY Flavopiridol, when administered by a 30-min intravenous bolus followed by a 4-h continuous intravenous infusion, is active in high-risk, refractory chronic lymphocytic leukemia. Careful monitoring and aggressive intervention for tumor lysis syndrome and hyperkalemia is necessary for safe drug administration. Further studies to optimize the dose and schedule of administration, and to study this drug in other hematologic malignancies, are ongoing.
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Affiliation(s)
- Beth A Christian
- Division of Hematology and Oncology, Ohio State University, Columbus, Ohio 43210, USA
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Abstract
Mantle cell lymphoma (MCL) still carries a poor prognosis. Chemoimmunotherapy (combination with rituximab) is the routine first-line therapy, although data strongly suggest a benefit from intensification through high-dose therapy with stem cell transplantation consolidation or dose-intense chemotherapy with HyperCVAD (fractionated cyclophosphamide/vincristine/doxorubicin/dexamethasone)/rituximab. Unfortunately, most patients still experience relapse, and a multitude of novel agents are currently being tested in this setting, including proteasome inhibitors with bortezomib (the first of its class and first Food and Drug Administration-approved drug in MCL), mammalian target of rapamycin inhibitors, Bcl-2 inhibitors, and antiangiogenesis agents, among others. Because of the relative rarity of the disease-MCL represents 6% of non-Hodgkin lymphoma-an obvious effort is needed to enroll patients on clinical trials. Not surprisingly, as in other non-Hodgkin lymphomas, MCL appears more and more as a heterogeneous disease, which might impact future clinical trial design through pharmacogenomics and hopefully help us develop smaller "molecular" relevant trials.
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Affiliation(s)
- Andre Goy
- Lymphoma Division, Hackensack University Medical Center, NJ 07601, USA.
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Jares P, Colomer D, Campo E. Genetic and molecular pathogenesis of mantle cell lymphoma: perspectives for new targeted therapeutics. Nat Rev Cancer 2007; 7:750-62. [PMID: 17891190 DOI: 10.1038/nrc2230] [Citation(s) in RCA: 348] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Mantle cell lymphoma (MCL) is a well-defined lymphoid malignancy characterized by a rapid clinical evolution and poor response to current therapeutic protocols. The genetic and molecular mechanisms involved in its pathogenesis combine the dysregulation of cell proliferation and survival pathways with a high level of chromosome instability that seems related to the disruption of the DNA damage response pathway. Understanding these mechanisms and how they affect tumour behaviour is providing the rationale for the identification of reliable predictors of clinical evolution and the design of innovative therapeutic strategies that could open new avenues for the treatment of patients with MCL.
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Affiliation(s)
- Pedro Jares
- Haematopathology Section, Laboratory of Pathology, and Genomics Unit, Hospital Clinic, Institut de Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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Christian BA, Fischer B, Blum KA, Brooker-McEldowney M, Moran ME, Andritsos LA, Phelps MA, Dalton JT, Colevas AD, Byrd JC, Grever MR, Lin TS. Flavopiridol in Chronic Lymphocytic Leukemia. ACTA ACUST UNITED AC 2007. [DOI: 10.3816/clk.2007.n.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Mantle cell lymphoma (MCL) is characterised by cell cycle dysregulation and a defective DNA damage response pathway. An evolving understanding of these processes has provided the rationale for development of novel agents targeting various steps that appear to be involved in lymphomagenesis and disease progression. Cyclin D1, overexpressed in nearly 100% of MCL, and the cyclin-dependent kinases were among the first rational targets identified. Therapies focusing on the PI3K/Akt pathway, the tumour microenvironment, and cell surface markers are also in various stages of exploration. Here, the authors discuss the rationale for developing targeted therapies and discuss future challenges in combining some of these agents.
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Affiliation(s)
- Peter Martin
- Weill Medical College of Cornell University and New York Presbyterian Hospital, Center for Lymphoma and Myeloma, Division of Hematology and Medical Oncology, Starr Building Room 340, 520 East 70th Street, New York, NY 10021, USA
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Wanner K, Hipp S, Oelsner M, Ringshausen I, Bogner C, Peschel C, Decker T. Mammalian target of rapamycin inhibition induces cell cycle arrest in diffuse large B cell lymphoma (DLBCL) cells and sensitises DLBCL cells to rituximab. Br J Haematol 2006; 134:475-84. [PMID: 16856892 DOI: 10.1111/j.1365-2141.2006.06210.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a common lymphoma entity. Although a significant amount of DLBCL patients can be cured with modern chemotherapeutic regimens, a substantial proportion of patients die because of progressive disease. Therefore, new therapeutic strategies are clearly needed. Inhibitors of mTOR [mammalian target of rapamycin (Rap)] represent a new class of antiproliferative drugs with applications as immunosuppressive and anticancer agents. Extensive safety data exist on the mTOR inhibitor RAD001, which is already approved as an immunosuppressant in organ transplant recipients. Rap and RAD001 inhibited cell cycle progression in DLBCL cells by inducing a G1 arrest without inducing apoptosis. Phosphorylation of the main targets of mTOR, p70 s6 kinase and 4-EBP-1 was reduced in cells cultured in the presence of RAD001. Cell cycle arrest was accompanied by reduced phosphorylation of the retinoblastoma protein (RB) as well as reduced expression of cyclin D3 and A in all cell lines. Although the effect of the chemotherapeutic agent vincristine (vin) was not enhanced by RAD001, rituximab-induced cytotoxicity was augmented in the rituximab-sensitive cell lines. mTOR inhibition is a promising therapeutic strategy in DLBCL by inducing a G1 arrest and augments rituximab-induced cytotoxicity. Therefore, combination of these drugs might be an interesting new therapeutic approach in DLBCL patients.
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MESH Headings
- Adaptor Proteins, Signal Transducing/metabolism
- Annexin A5/analysis
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Murine-Derived
- Cell Cycle Proteins/metabolism
- Cell Line, Tumor
- Cell Proliferation/drug effects
- Electrophoretic Mobility Shift Assay
- Everolimus
- Flow Cytometry
- G1 Phase
- Humans
- Immunosuppressive Agents/therapeutic use
- In Situ Nick-End Labeling
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/metabolism
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/metabolism
- Lymphoma, Non-Hodgkin/pathology
- Oncogene Protein v-akt/metabolism
- PTEN Phosphohydrolase/metabolism
- Phosphoproteins/metabolism
- Phosphorylation
- Protein Kinase Inhibitors/therapeutic use
- Protein Kinases/metabolism
- Retinoblastoma Protein/metabolism
- Ribosomal Protein S6 Kinases, 70-kDa/metabolism
- Rituximab
- Sirolimus/analogs & derivatives
- Sirolimus/therapeutic use
- TOR Serine-Threonine Kinases
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Affiliation(s)
- Kathrin Wanner
- IIIrd Department of Medicine, Technical University of Munich, Munich, Germany
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36
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Abstract
Mantle cell lymphoma (MCL) is one of the most challenging lymphomas to treat. In the first-line setting, high-dose therapy (HDT) and autologous stem cell transplantation or hyperCVAD/rituximab suggest benefit, especially in patients aged < 60 years. Nucleoside analogue-based regimens represent an alternate option in patients ineligible for HDT. Fludarabine in combination with cyclophosphamide or mitoxantrone has shown activity, and the results were superior with the addition of rituximab. Other cytotoxic agents, such as cladribine, clofarabine, or bendamustin, showed promising activity as well. A variety of new monoclonal antibody (MoAb) agents, such as humanized anti-CD20, alemtuzumab, anti-HLA-DR, anti-CD22 (as an immunotoxin carrier), anti-CD40, as well as MoAb-targeting TRAIL-R1 and TRAIL-R2 are being tested. Radioimmunotherapy with Yttrium 90-ibritumomab tiuxetan and Iodine 131 tositumomab have been tested alone or in combination with chemotherapy, including as part of HDT and autologous stem cell transplantation, in which they showed the best results. New vaccine modalities are exploring the use of tumor cell-based vaccines or of agents that block or activate costimulatory pathways/molecules, such as CTLA-4-Ig. Allogenic transplantation represents a potential curative option for MCL, especially nonmyeloablative transplantation, more feasible in that population. A plethora of novel biologic agents have surfaced, such as bortezomib, temsirolimus, thalidomide, lenalidomide, MoAb anti-vascular endothelial growth factor or vascular endothelial growth factor-Trap, and flavopiridol. Other targets include gene transcription through histone regulation; nuclear factor-ķB pathway; protein kinase C inhibitors; small-molecules targeting apoptosis, such as antisense Bcl-2, pan-Bcl-2 family member inhibitors; MoAb agonists of cell death receptors; caspases regulators (inhibitors of apoptosis proteins, survivin); and MDM2 antagonist regulators of p53. A molecular approach to define biomarkers might help identify subgroups of patients and help develop rational therapies.
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Affiliation(s)
- Andre Goy
- Hackensack University Medical Center, Hackensack, NJ 07601, USA.
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37
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38
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Abstract
The World Health Organization has included different types of lymphoma under the aggressive category. In the US, diffuse large B-cell lymphoma is the most common aggressive lymphoma and accounts for > 30% of the 55,000 new cases diagnosed annually. Recent advances in the knowledge of the molecular biology have provided an increased understanding of the heterogeneity of non-Hodgkin's lymphoma. New treatments, especially those with the use of monoclonal antibodies, are improving both the survival and the response rate.
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Affiliation(s)
- Luis Fayad
- Department of Lymphoma/Myeloma, University of Texas, MD Anderson Cancer Center, Box # 429, Houston, TX 77030, USA
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39
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Abstract
Cyclin-dependent kinases (cdks) are critical regulators of cell cycle progression and RNA transcription. A variety of genetic and epigenetic events cause universal overactivity of the cell cycle cdks in human cancer, and their inhibition can lead to both cell cycle arrest and apoptosis. However, built-in redundancy may limit the effects of highly selective cdk inhibition. Cdk4/6 inhibition has been shown to induce potent G1 arrest in vitro and tumor regression in vivo; cdk2/1 inhibition has the most potent effects during the S and G2 phases and induces E2F transcription factor-dependent cell death. Modulation of cdk2 and cdk1 activities also affects survival checkpoint responses after exposure to DNA-damaging and microtubule-stabilizing agents. The transcriptional cdks phosphorylate the carboxy-terminal domain of RNA polymerase II, facilitating efficient transcriptional initiation and elongation. Inhibition of these cdks primarily affects the accumulation of transcripts with short half-lives, including those encoding antiapoptosis family members, cell cycle regulators, as well as p53 and nuclear factor-kappa B-responsive gene targets. These effects may account for apoptosis induced by cdk9 inhibitors, especially in malignant hematopoietic cells, and may also potentiate cytotoxicity mediated by disruption of a variety of pathways in many transformed cell types. Current work is focusing on overcoming pharmacokinetic barriers that hindered development of flavopiridol, a pan-cdk inhibitor, as well as assessing novel classes of compounds potently targeting groups of cell cycle cdks (cdk4/6 or cdk2/1) with variable effects on the transcriptional cdks 7 and 9. These efforts will establish whether the strategy of cdk inhibition is able to produce therapeutic benefit in the majority of human tumors.
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Affiliation(s)
- Geoffrey I Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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40
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Abstract
The cell cycle represents a series of tightly integrated events that allow the cell to grow and proliferate. Critical parts of the cell cycle machinery are the cyclin-dependent kinases (CDKs), which, when activated, provide a means for the cell to move from one phase of the cell cycle to the next. The CDKs are regulated positively by cyclins and regulated negatively by naturally occurring CDK inhibitors (CDKIs). Cancer represents a dysregulation of the cell cycle such that cells that overexpress cyclins or do not express the CDKIs continue to undergo unregulated cell growth. The cell cycle also serves to protect the cell from DNA damage. Thus, cell cycle arrest, in fact, represents a survival mechanism that provides the tumor cell the opportunity to repair its own damaged DNA. Thus, abrogation of cell cycle checkpoints, before DNA repair is complete, can activate the apoptotic cascade, leading to cell death. Now in clinical trials are a series of targeted agents that directly inhibit the CDKs, inhibit unrestricted cell growth, and induce growth arrest. Recent attention has also focused on these drugs as inhibitors of transcription. In addition, there are now agents that abrogate the cell cycle checkpoints at critical time points that make the tumor cell susceptible to apoptosis. An understanding of the cell cycle is critical to understanding how best to clinically develop these agents, both as single agents and in combination with chemotherapy.
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Affiliation(s)
- Gary K Schwartz
- Department of Medicine, Division of Solid Tumor Oncology, Gastrointestinal Oncology Service, New York, NY, USA.
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41
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Affiliation(s)
- Ali Hachem
- University of Maryland Greenebaum Cancer Center, 9-011 BRB, 655 West Baltimore St, Baltimore MD 21201, USA
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42
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Byrd JC, Peterson BL, Gabrilove J, Odenike OM, Grever MR, Rai K, Larson RA. Treatment of Relapsed Chronic Lymphocytic Leukemia by 72-Hour Continuous Infusion or 1-Hour Bolus Infusion of Flavopiridol: Results from Cancer and Leukemia Group B Study 19805. Clin Cancer Res 2005; 11:4176-81. [PMID: 15930354 DOI: 10.1158/1078-0432.ccr-04-2276] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Flavopiridol has in vitro activity in chronic lymphocytic leukemia (CLL) and promotes apoptosis independent of p53 function or prior fludarabine exposure. We sought to determine if flavopiridol has activity in previously treated CLL using two schedules of administration. PATIENTS AND METHODS Patients with previously treated CLL were enrolled in two sequentially done phase II studies. Patients in the first trial received flavopiridol (50 mg/m(2)/d) as a continuous infusion (CI) for 72 hours every 2 weeks. Patients in the second trial received flavopiridol 50 mg/m(2) as a 1-hour bolus (IVB) daily for 3 days repeated every 3 weeks. Patients received up to 12 (CI cohort) or 8 (IVB cohort) cycles of therapy. RESULTS Fifteen patients were enrolled in the 72-hour CI phase II trial; 6 (40%) had intermediate-risk (Rai stage I or II) and 9 (60%) had high-risk (Rai stage III and IV) stages. No responses were noted in this group; 27% had stable disease and 73% had progressive disease. Thirty-six patients were enrolled in the second IVB trial, with 13 (36%) having intermediate and 23 (64%) having high-risk disease. Four patients (11%) had partial responses, 19 (53%) had stable disease, and 13 (36%) had progressive disease. The progression-free survival for responders in the IVB trial was 3, 3, 9, and 19 months. The median progression-free survival was 2 months [95% confidence interval (95% CI), 1.8-3.8] for patients in the CI trial and 3 months (95% CI, 2.5-7.4) for the IVB trial. The median overall survival was 27 months (95% CI, 20-42) for the CI trial and 24 months (95% CI, 18-31) for the IVB trial. Toxicity was manageable and included mainly myelosuppression, infections, diarrhea, and fatigue. CONCLUSIONS Flavopiridol has modest, schedule-dependent clinical activity in relapsed CLL and warrants future investigation utilizing alternative schedules of administration.
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Affiliation(s)
- John C Byrd
- Division of Hematology-Oncology, Department of Medicine, The Ohio State University, Columbus, Ohio 43210, USA.
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43
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Affiliation(s)
- Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Benson C, Kaye S, Workman P, Garrett M, Walton M, de Bono J. Clinical anticancer drug development: targeting the cyclin-dependent kinases. Br J Cancer 2005; 92:7-12. [PMID: 15558073 PMCID: PMC2361734 DOI: 10.1038/sj.bjc.6602229] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2004] [Revised: 10/07/2004] [Accepted: 10/11/2004] [Indexed: 12/03/2022] Open
Abstract
Cell division involves a cyclical biochemical process composed of several step-wise reactions that have to occur once per cell cycle. Dysregulation of cell division is a hallmark of all cancers. Genetic and epigenetic mechanisms frequently result in deranged expression and/or activity of cell-cycle proteins including the cyclins, cyclin-dependent kinases (Cdks), Cdk inhibitors and checkpoint control proteins. The critical nature of these proteins in cell cycling raises hope that targeting them may result in selective cytotoxicity and valuable anticancer activity.
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Affiliation(s)
- C Benson
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - S Kaye
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - P Workman
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - M Garrett
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - M Walton
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - J de Bono
- Section of Medicine and Cancer Research UK Centre for Cancer Therapeutics, Institute for Cancer Research and Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
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45
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Affiliation(s)
- Manish A Shah
- Department of Medicine, Division of Solid Tumor Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Abstract
Flavopiridol has potent anti-proliferative properties due to its direct action of binding to the ATP-binding pocket of cyclin-dependent kinases (cdks), and due to its indirect action reducing levels of other cyclins and cdk inhibitors, contributing to its pleiotropic effects. Flavopiridol is a potent apoptotic agent due to its ability to cause cell death in cycling as well as non-cycling tumor cells; to down-regulate important cell survival proteins, such as survivin, through inhibition of the phosphorylation of Thr34; to increase sensitivity for S phase cells to drug treatment by modulating E2F-1 transcription factor activity in tumor cells; to induce both caspase-dependent and -independent mitochondrial cell death pathways; and to inhibit the activation of p-Akt which in turn inhibits activation of NF-kappaB. Flavopiridol possesses several important anti-angiogenic activities including induction of apoptosis of endothelial cells; inhibition of the hypoxic induction of vascular endothelial growth factor and/or its production under hypoxic conditions through inhibition of HIF-1alpha transcription; and decreased secretion of matrix metalloproteinases that is linked with significant inhibition of invasive potential in Matrigel assays. Taken together, the anti-proliferative and anti-angiogenic properties of flavopiridol may contribute to its anti-tumor activities observed in several preclinical animal models of human cancers including prostate, lymphoid, head and neck, colon, and glioma. These promising preclinical observations opened the way for phase I and II clinical trials. Given the low toxicity profile of flavopiridol used as a single agent in patients, combination therapy now offers numerous opportunities in the near future to improve the efficacy of flavopiridol in the treatment of refractory cancers.
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Affiliation(s)
- Elizabeth W Newcomb
- Department of Pathology, New York University Cancer Institute, New York University School of Medicine, New York, NY 10016, USA.
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Liu G, Gandara DR, Lara PN, Raghavan D, Doroshow JH, Twardowski P, Kantoff P, Oh W, Kim K, Wilding G. A Phase II Trial of Flavopiridol (NSC #649890) in Patients with Previously Untreated Metastatic Androgen-Independent Prostate Cancer. Clin Cancer Res 2004; 10:924-8. [PMID: 14871968 DOI: 10.1158/1078-0432.ccr-03-0050] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Flavopiridol is a cyclin-dependent kinase inhibitor with preclinical activity against prostate cancer cell lines. A Phase II trial was conducted to determine the activity of flavopiridol in patients with metastatic hormone-refractory prostate cancer. EXPERIMENTAL DESIGN A total of 36 patients was enrolled from several institutions and treated with a 72-h continuous infusion of flavopiridol every 14 days at the eventual starting dose of 40 mg/m(2)/day. Dose escalation up to 60 mg/m(2)/day was permitted if no significant toxicity was observed. Responses were assessed every 12 weeks. Only those patients completing four courses of the 72-h infusion were considered evaluable for response because the primary objective was to determine progression-free survival at 6 months given the cytostatic nature of the agent. RESULTS This study was conducted in a two-stage fashion. During the first stage, at least 20 evaluable patients needed to be enrolled to assess response. There were 22 of 36 patients evaluable for response. No objective responses were observed. Only 4 patients had stable disease for 16, 26, 29, and 48 weeks, respectively, stopping the trial by design as only 3 of 22 (14%) of the patients met the 6-month progression-free survival end point. The most common toxicities were diarrhea (grade 1 and 2) and nausea, although some grade 3 and 4 diarrhea (11 and 6%, respectively) were evident. CONCLUSIONS Flavopiridol has disappointing single-agent activity in hormone-refractory prostate cancer when administered at this dose and schedule. Its use in prostate cancer should be reserved for evaluation in combination therapies or alternative schedules.
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Affiliation(s)
- Glenn Liu
- Medical Oncology Section, Department of Medicine, University of Wisconsin Comprehensive Cancer Center, 600 Highland Avenue, Madison, WI 53792, USA
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Affiliation(s)
- Francesco Bertoni
- Experimental Oncology, Oncology Institute of Southern Switzerland, Via Vincenzo Vela 6, Stabile IRB, 6500 Bellinzona, Switzerland.
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49
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Affiliation(s)
- T S Lin
- Division of Hematology and Oncology, The Ohio State University, Columbus, OH 43210, USA
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50
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Abstract
Mantle cell lymphoma is an aggressive non-Hodgkin's lymphoma that remains incurable with current chemotherapeutic approaches. Despite response rates to many regimens of 50% to 70%, the disease typically progresses after chemotherapy with a median survival time of approximately 3 years. There is no clear standard approach for treating mantle cell lymphoma, making it critical that appropriate patients be enrolled in clinical trials. Off protocol, chemotherapy with chlorambucil, CVP (cyclophosphamide, vincristine, and prednisone), or CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) can be used in patients who are not candidates for aggressive therapy. Intensive combination chemotherapy regimens have high response rates and may prolong time to progressive disease. High-dose therapy with autologous stem cell transplantation may, but does not appear to, provide longer time to progression, although it may improve survival. For young patients with matched donors, allogeneic transplant is promising in the limited numbers of patients treated. Other agents, including rituximab, fludarabine, and cladribine, have demonstrated activity, but these agents do not appear to offer survival advantages over combination chemotherapy.
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Affiliation(s)
- John J Densmore
- Division of Hematology/Oncology, University of Virginia Health System, Box 800716, Charlottesville, VA 22908, USA.
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