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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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2
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Tam CS. Upfront therapy: the case for continuous treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:55-58. [PMID: 34889433 PMCID: PMC8791150 DOI: 10.1182/hematology.2021000232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Both BTKi and BCL2i are regarded as standards of care for frontline treatment of CLL. In this paper, I present the arguments for favoring BTKi as initial therapy. Venetoclax-based regimens have the advantage of being fixed in duration, but patients with select high-risk features may experience inferior PFS relative to those without high-risk features.
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Affiliation(s)
- Constantine S. Tam
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia; and The Royal Melbourne Hospital, Parkville, Victoria, Australia
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3
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Tomić K, Karan-Đurašević T, Vuković V, Mihaljević B, Antić D. Clinical significance of TP53 aberrations and IGHV mutational status in chronic lymphocytic leukemia. MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-28969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a very heterogeneous disease with a variable clinical course. On the one side of the spectrum, there are patients with aggressive and resistant disease, of which they die only a few months after diagnosis while, on the other side, there are patients with an indolent, slowly progressive disease that does not require treatment for decades. The reasons for this are only partially known, but they have been the subject of numerous scientific studies during the last several decades. Consequently, the concept of prognostic and predictive factors in CLL have emerged, which aims to predict the clinical course and its therapeutic outcome. With the improvement of understanding the pathophysiology of this disease, the lists of prognostic and predictive factors are getting longer every year, but they also overlap. In this review, we singled out the aberrations of the TP53 gene and the IGHV (immunoglobulin heavy variable) gene mutational status as the two most important and most studied factors that have both prognostic and predictive significance.
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4
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Hatswell AJ, Thompson GJ, Maroudas PA, Sofrygin O, Delea TE. Estimating outcomes and cost effectiveness using a single-arm clinical trial: ofatumumab for double-refractory chronic lymphocytic leukemia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:8. [PMID: 28559746 PMCID: PMC5446681 DOI: 10.1186/s12962-017-0071-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/23/2017] [Indexed: 11/25/2022] Open
Abstract
Background Ofatumumab (Arzerra®, Novartis) is a treatment for chronic lymphocytic leukemia refractory to fludarabine and alemtuzumab [double refractory (DR-CLL)]. Ofatumumab was licensed on the basis of an uncontrolled Phase II study, Hx-CD20-406, in which patients receiving ofatumumab survived for a median of 13.9 months. However, the lack of an internal control arm presents an obstacle for the estimation of comparative effectiveness. Methods The objective of the study was to present a method to estimate the cost effectiveness of ofatumumab in the treatment of DR-CLL. As no suitable historical control was available for modelling, the outcomes from non-responders to ofatumumab were used to model the effect of best supportive care (BSC). This was done via a Cox regression to control for differences in baseline characteristics between groups. This analysis was included in a partitioned survival model built in Microsoft® Excel with utilities and costs taken from published sources, with costs and quality-adjusted life years (QALYs) were discounted at a rate of 3.5% per annum. Results Using the outcomes seen in non-responders, ofatumumab is expected to add approximately 0.62 life years (1.50 vs. 0.88). Using published utility values this translates to an additional 0.30 QALYs (0.77 vs. 0.47). At the list price, ofatumumab had a cost per QALY of £130,563, and a cost per life year of £63,542. The model was sensitive to changes in assumptions regarding overall survival estimates and utility values. Conclusions This study demonstrates the potential of using data for non-responders to model outcomes for BSC in cost-effectiveness evaluations based on single-arm trials. Further research is needed on the estimation of comparative effectiveness using uncontrolled clinical studies.
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Affiliation(s)
- Anthony J Hatswell
- University College London, London, UK.,GlaxoSmithKline UK, Stockley Park West, Uxbridge, UK.,BresMed, 84 Queen Street, Sheffield, S1 2DW UK
| | | | | | - Oleg Sofrygin
- Interdepartmental Group in Biostatistics, University of California, Berkeley, CA USA
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Butler LA, Tam CS, Seymour JF. Dancing partners at the ball: Rational selection of next generation anti-CD20 antibodies for combination therapy of chronic lymphocytic leukemia in the novel agents era. Blood Rev 2017; 31:318-327. [PMID: 28499646 DOI: 10.1016/j.blre.2017.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023]
Abstract
The anti-CD20 antibodies represent a major advancement in the therapeutic options available for chronic lymphocytic leukemia. The addition of rituximab, ofatumumab and obinutuzumab to various chemotherapy regimens has led to considerable improvements in both response and survival. Ocaratuzumab, veltuzumab and ublituximab are currently being explored within the trial setting. We review the current status of these antibodies, and discuss how their mechanisms of action may impact on the choice of combinations with novel small molecule agents.
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Affiliation(s)
- L A Butler
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - C S Tam
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia
| | - J F Seymour
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia.
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6
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Winqvist M, Asklid A, Andersson PO, Karlsson K, Karlsson C, Lauri B, Lundin J, Mattsson M, Norin S, Sandstedt A, Hansson L, Österborg A. Real-world results of ibrutinib in patients with relapsed or refractory chronic lymphocytic leukemia: data from 95 consecutive patients treated in a compassionate use program. A study from the Swedish Chronic Lymphocytic Leukemia Group. Haematologica 2016; 101:1573-1580. [PMID: 27198718 PMCID: PMC5479603 DOI: 10.3324/haematol.2016.144576] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/18/2016] [Indexed: 12/22/2022] Open
Abstract
Ibrutinib, a Bruton's tyrosine kinase inhibitor is approved for relapsed/refractory and del(17p)/TP53 mutated chronic lymphocytic leukemia. Discrepancies between clinical trials and routine health-care are commonly observed in oncology. Herein we report real-world results for 95 poor prognosis Swedish patients treated with ibrutinib in a compassionate use program. Ninety-five consecutive patients (93 chronic lymphocytic leukemia, 2 small lymphocytic leukemia) were included in the study between May 2014 and May 2015. The median age was 69 years. 63% had del(17p)/TP53 mutation, 65% had Rai stage III/IV, 28% had lymphadenopathy ≥10cm. Patients received ibrutinib 420 mg once daily until progression. At a median follow-up of 10.2 months, the overall response rate was 84% (consistent among subgroups) and 77% remained progression-free. Progression-free survival and overall survival were significantly shorter in patients with del(17p)/TP53 mutation (P=0.017 and P=0.027, log-rank test); no other factor was significant in Cox proportional regression hazards model. Ibrutinib was well tolerated. Hematomas occurred in 46% of patients without any major bleeding. Seven patients had Richter's transformation. This real-world analysis on consecutive chronic lymphocytic leukemia patients from a well-defined geographical region shows the efficacy and safety of ibrutinib to be similar to that of pivotal trials. Yet, del(17p)/TP53 mutation remains a therapeutic challenge. Since not more than half of our patients would have qualified for the pivotal ibrutinib trial (RESONATE), our study emphasizes that real-world results should be carefully considered in future with regards to new agents and new indications in chronic lymphocytic leukemia.
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MESH Headings
- Adenine/analogs & derivatives
- Aged
- Aged, 80 and over
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Chromosome Aberrations
- Compassionate Use Trials
- Disease Progression
- Drug Resistance, Neoplasm
- Female
- Humans
- Kaplan-Meier Estimate
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Neoplasm Staging
- Piperidines
- Proportional Hazards Models
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/therapeutic use
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/therapeutic use
- Recurrence
- Retreatment
- Retrospective Studies
- Sweden
- Treatment Outcome
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Affiliation(s)
- Maria Winqvist
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Asklid
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - P O Andersson
- Department of Hematology, South Älvsborg Hospital, Borås, Sweden
| | - Karin Karlsson
- Department of Hematology and Vascular Disorders, Skåne University Hospital, Lund, Sweden
| | - Claes Karlsson
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Birgitta Lauri
- Department of Hematology, Sunderby Hospital, Sunderbyn Luleå, Sweden
| | - Jeanette Lundin
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Mattsson
- Department of Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Stefan Norin
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Sandstedt
- Department of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Lotta Hansson
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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Asklid A, Winqvist M, Eketorp Sylvan S, Mattsson A, Björgvinsson E, Søltoft F, Repits J, Diels J, Österborg A, Hansson L. Outcomes of second-line treatment in chronic lymphocytic leukemia - a population-based study from a well defined geographical region between 2003 and 2013. Leuk Lymphoma 2016; 58:1219-1223. [PMID: 27894205 DOI: 10.1080/10428194.2016.1246727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Anna Asklid
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,b Department of Oncology , Karolinska University Hospital , Stockholm , Sweden
| | - Maria Winqvist
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
| | | | - Agnes Mattsson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,c Department of Internal Medicine , Södersjukhuset , Stockholm , Sweden
| | - Einar Björgvinsson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,b Department of Oncology , Karolinska University Hospital , Stockholm , Sweden
| | | | | | | | - Anders Österborg
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
| | - Lotta Hansson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
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8
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Jacobs RW, Awan FT, Leslie LA, Usmani SZ, Ghosh N. The shrinking role of chemotherapy in the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:1177-1187. [DOI: 10.1080/17474086.2016.1254545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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9
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Winqvist M, Mozaffari F, Palma M, Eketorp Sylvan S, Hansson L, Mellstedt H, Österborg A, Lundin J. Phase I-II study of lenalidomide and alemtuzumab in refractory chronic lymphocytic leukemia (CLL): effects on T cells and immune checkpoints. Cancer Immunol Immunother 2016; 66:91-102. [PMID: 27815572 PMCID: PMC5222940 DOI: 10.1007/s00262-016-1922-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/27/2016] [Indexed: 11/21/2022]
Abstract
This phase I–II study explored safety, immunomodulatory and clinical effects of lenalidomide (weeks 1–16) and alemtuzumab (weeks 5–16) in 23 patients with refractory chronic lymphocytic leukemia. Most patients had Rai stage III/IV disease and were heavily pretreated (median 4 prior therapies), and 61% had del(17p)/del(11q). Eleven of 19 evaluable patients (58%) responded, with a median response duration of 12 months (1–29+); time to progression was short in non-responders. Lenalidomide had a narrow therapeutic dose range, 2.5 mg/day was not efficient, and maximum tolerated dose was 5 mg/day. Grade 3–4 neutropenia and thrombocytopenia occurred in 84 and 55%, 30% had febrile neutropenia, and CMV-reactivation requiring valganciclovir occurred in 30% of patients. The frequency of proliferating (Ki67+) CD8+ T cells was increased at week 4, with further increase in both the CD4+ and CD8+ subsets (p < 0.01 and <0.05), which was accompanied by significant upregulation of HLA-DR after addition of alemtuzumab. Antigen-experienced cells increased at week 4 as the frequency of effector memory cells increased in the CD8+ subset (p < 0.003), while effector cells decreased in both the CD8+ and CD4+ subsets (p < 0.0001 and p < 0.01). The Th1/Th2 balance was unchanged at week 4 but shifted toward a Th2 profile after combination therapy. At end of treatment, the frequency of Th17 and regulatory T cells was reduced (p < 0.01), naïve T cells decreased, and effector memory T cells increased (p < 0.05 and p < 0.01). Granzyme B+ T cells increased at 30-week follow-up (p < 0.05). PD-1 expression was unaffected. In conclusion, low-dose lenalidomide and alemtuzumab induced major perturbations of T cells, including increased proliferative activity and cytotoxic potential.
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Affiliation(s)
- Maria Winqvist
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden. .,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
| | - Fariba Mozaffari
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Marzia Palma
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Lotta Hansson
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Mellstedt
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Jeanette Lundin
- Department of Hematology, Karolinska University Hospital Solna, 171 76, Stockholm, Sweden.,Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
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10
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Minervini CF, Cumbo C, Orsini P, Brunetti C, Anelli L, Zagaria A, Minervini A, Casieri P, Coccaro N, Tota G, Impera L, Giordano A, Specchia G, Albano F. TP53 gene mutation analysis in chronic lymphocytic leukemia by nanopore MinION sequencing. Diagn Pathol 2016; 11:96. [PMID: 27724982 PMCID: PMC5057401 DOI: 10.1186/s13000-016-0550-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/07/2016] [Indexed: 01/26/2023] Open
Abstract
Background The assessment of TP53 mutational status is becoming a routine clinical practice for chronic lymphocytic leukemia patients (CLL). A broad spectrum of molecular techniques has been employed so far, including both direct Sanger sequencing and next generation sequencing. Oxford Nanopore Technologies recently released the MinION an USB-interfaced sequencer. In this paper we report our experience, with the MinION technology for the detection of the TP53 gene mutation in CLL patients. Twelve CLL patients at diagnosis were included in this study. All except one patient showed the TP53 gene deletion in Fluorescence in situ hybridization experiments. Patients were investigated for TP53 mutation by Sanger and by MinION sequencing. Analysis by Sanger was performed according with the IARC protocol. Analysis by MinION was performed adopting a strategy based on long template PCR, read error correction, and post variant calling filtering. Results Due to the high error rate of nanopore technology, sequence data were both used directly and before correction with two different in silico methods: ALEC and nanocorrect. A mean error rate of 15 % was detected before correction that was reduced to 4-5 % after correction. Analysis by Sanger sequencing was able to detect four patients mutated for TP53. MinION analysis detected one more mutated patient previously not detected from Sanger. Conclusion In our hands, the Nanopore technology shows correlation with Sanger sequencing but more sensitive, manageable and less expensive, and therefore has proven to be a useful tool for TP53 gene mutation detection. Electronic supplementary material The online version of this article (doi:10.1186/s13000-016-0550-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Crescenzio Francesco Minervini
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Cosimo Cumbo
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Paola Orsini
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Claudia Brunetti
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Luisa Anelli
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Antonella Zagaria
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Angela Minervini
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Paola Casieri
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Nicoletta Coccaro
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Giuseppina Tota
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Luciana Impera
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Annamaria Giordano
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Giorgina Specchia
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy
| | - Francesco Albano
- Department of Emergency and Organ Transplantation (D.E.T.O.) Hematology Section, University of Bari, P.zza G. Cesare, 11 70124, Bari, Italy.
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11
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Yu L, Kim HT, Kasar S, Benien P, Du W, Hoang K, Aw A, Tesar B, Improgo R, Fernandes S, Radhakrishnan S, Klitgaard J, Lee C, Getz G, Setlur SR, Brown JR. Survival of Del17p CLL Depends on Genomic Complexity and Somatic Mutation. Clin Cancer Res 2016; 23:735-745. [PMID: 27503198 DOI: 10.1158/1078-0432.ccr-16-0594] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/17/2016] [Accepted: 07/17/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Chronic lymphocytic leukemia (CLL) with 17p deletion typically progresses quickly and is refractory to most conventional therapies. However, some del(17p) patients do not progress for years, suggesting that del(17p) is not the only driving event in CLL progression. We hypothesize that other concomitant genetic abnormalities underlie the clinical heterogeneity of del(17p) CLL. EXPERIMENTAL DESIGN We profiled the somatic mutations and copy number alterations (CNA) in a large group of del(17p) CLLs as well as wild-type CLL and analyzed the genetic basis of their clinical heterogeneity. RESULTS We found that increased somatic mutation number associates with poor overall survival independent of 17p deletion (P = 0.003). TP53 mutation was present in 81% of del(17p) CLL, mostly clonal (82%), and clonal mutations with del(17p) exhibit shorter overall survival than subclonal mutations with del(17p) (P = 0.019). Del(17p) CLL has a unique driver mutation profile, including NOTCH1 (15%), RPS15 (12%), DDX3X (8%), and GPS2 (6%). We found that about half of del(17p) CLL cases have recurrent deletions at 3p, 4p, or 9p and that any of these deletions significantly predicts shorter overall survival. In addition, the number of CNAs, but not somatic mutations, predicts shorter time to treatment among patients untreated at sampling. Indolent del(17p) CLLs were characterized by absent or subclonal TP53 mutation and few CNAs, with no difference in somatic mutation number. CONCLUSIONS We conclude that del(17p) has a unique genomic profile and that clonal TP53 mutations, 3p, 4p, or 9p deletions, and genomic complexity are associated with shorter overall survival. Clin Cancer Res; 23(3); 735-45. ©2016 AACR.
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Affiliation(s)
- Lijian Yu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Haesook T Kim
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA
| | - Siddha Kasar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | | | - Wei Du
- Brigham and Women's Hospital, Boston, MA
| | - Kevin Hoang
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Aw
- Division of Hematology, The Ottawa Hospital, Ottawa, Ontario
| | - Bethany Tesar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Reina Improgo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Stacey Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Josephine Klitgaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
| | - Charles Lee
- The Jackson Laboratory for Genomic Medicine, Farmington, CT
| | - Gad Getz
- Broad Institute of Harvard and MIT, Cambridge, MA.,Massachusetts General Hospital Cancer Center and Department of Pathology, Boston, MA
| | - Sunita R Setlur
- Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.,Harvard Medical School, Boston, MA
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12
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Routledge DJM, Bloor AJC. Recent advances in therapy of chronic lymphocytic leukaemia. Br J Haematol 2016; 174:351-67. [DOI: 10.1111/bjh.14184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
| | - Adrian J. C. Bloor
- Department of Haematology; The Christie NHS Foundation Trust; Manchester UK
- University of Manchester; Manchester UK
- Manchester Academic Health Science Centre; Manchester UK
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Smolej L, Šimkovič M. Practical approach to management of chronic lymphocytic leukemia. Arch Med Sci 2016; 12:448-56. [PMID: 27186193 PMCID: PMC4848353 DOI: 10.5114/aoms.2016.55424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 10/11/2014] [Indexed: 11/17/2022] Open
Abstract
Revolutionary progress has recently changed the landscape of chronic lymphocytic leukemia (CLL). Powerful prognostic factors, especially p53 mutation and/or deletion and IGHV mutation status, have refined individual patient prognosis. Purine analogs and monoclonal antibodies paved the way from palliative treatment to chemoimmunotherapy capable of eradication of minimal residual disease and prolongation of survival. Obinutuzumab (GA-101) and ofatumumab have been recently approved for the treatment of comorbid patients. Bendamustine is available for first-line treatment of patients ineligible for fludarabine, cyclophosphamide, and rituximab (FCR). High-dose glucocorticoids combined with rituximab represent a promising option for refractory CLL; ofatumumab is approved for fludarabine- and alemtuzumab-refractory patients. Allogeneic stem cell transplantation is the only curative option but is feasible in a highly selected group of patients only. The novel small molecule inhibitors ibrutinib and idelalisib have been recently approved for relapsed/refractory CLL. This review provides practical advice for diagnosis, prognostication and treatment of CLL.
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Affiliation(s)
- Lukáš Smolej
- 4 Department of Internal Medicine - Hematology, University Hospital Hradec Králové and Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Martin Šimkovič
- 4 Department of Internal Medicine - Hematology, University Hospital Hradec Králové and Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic
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14
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Österborg A, Udvardy M, Zaritskey A, Andersson PO, Grosicki S, Mazur G, Kaplan P, Steurer M, Schuh A, Montillo M, Kryachok I, Middeke JM, Kulyaba Y, Rekhtman G, Gorczyca M, Daly S, Chang CN, Lisby S, Gupta I. Phase III, randomized study of ofatumumab versus physicians’ choice of therapy and standard versus extended-length ofatumumab in patients with bulky fludarabine-refractory chronic lymphocytic leukemia. Leuk Lymphoma 2016; 57:2037-46. [DOI: 10.3109/10428194.2015.1122783] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Wendtner CM, Hallek M, Fraser GAM, Michallet AS, Hillmen P, Dürig J, Kalaycio M, Gribben JG, Stilgenbauer S, Buhler A, Kipps TJ, Purse B, Zhang J, De Bedout S, Mei J, Chanan-Khan A. Safety and efficacy of different lenalidomide starting doses in patients with relapsed or refractory chronic lymphocytic leukemia: results of an international multicenter double-blinded randomized phase II trial. Leuk Lymphoma 2016; 57:1291-9. [PMID: 26763349 DOI: 10.3109/10428194.2015.1128540] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The objective of this study was to evaluate the safety and efficacy of different lenalidomide starting doses in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). CLL patients were randomized to receive lenalidomide at initial doses of 5, 10, or 15 mg/d (N = 103). Doses were escalated by 5 mg every 28-d up to a maximum of 25 mg/d; dose reductions in up to 5 mg decrements were permitted. The most common grade ≥3 adverse events (AEs) were neutropenia and thrombocytopenia. Ten patients died during therapy (four deaths considered as related to lenalidomide); 12 patients experienced second primary malignancies. The most common cause for treatment discontinuation was AEs. Overall response rates were similar across arms. Progression-free survival and overall survival rates were longer in patients who escalated treatment (to 15 or 20 mg/d) versus those who did not. Lower starting doses allowed subsequent dose escalation of lenalidomide while maintaining an acceptable tolerability profile in patients with relapsed/refractory CLL.
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Affiliation(s)
- Clemens M Wendtner
- a Klinikum Schwabing, Academic Teaching Hospital of University of Munich , Munich , Germany ;,b Department I of Internal Medicine , University of Cologne , Cologne , Germany
| | - Michael Hallek
- b Department I of Internal Medicine , University of Cologne , Cologne , Germany ;,c Cologne Cluster of Excellence in Cellular Stress Responses in Aging-Associated Diseases (CECAD) , Cologne , Germany
| | - Graeme A M Fraser
- d Juravinski Cancer Centre, McMaster University , Hamilton , Ontario , Canada
| | - Anne-Sophie Michallet
- e Hospices Civils De Lyon, Centre Hospitalier Lyon Sud , Pierre Bénite , Lyon , France
| | | | - Jan Dürig
- g University Hospital Essen , Essen , Germany
| | | | - John G Gribben
- i Barts Cancer Institute, Queen Mary, University of London , London , UK
| | | | - Andreas Buhler
- j Department of Internal Medicine III , Ulm University , Ulm , Germany
| | - Thomas J Kipps
- k University of California San Diego Moores Cancer Center , La Jolla , CA , USA
| | | | | | | | - Jay Mei
- l Celgene Corporation , Summit , NJ , USA
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16
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Frustaci AM, Tedeschi A, Picardi P, Cairoli R, Montillo M. Clinical utility and patient considerations in the use of ofatumumab in chronic lymphocytic leukemia. Biologics 2015; 9:75-86. [PMID: 26425075 PMCID: PMC4583123 DOI: 10.2147/btt.s60503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Treatment aim for chronic lymphocytic leukemia has been radically changed over the past years from providing only a palliative approach to reaching disease eradication and improving survival. Ofatumumab is a monoclonal humanized antibody with peculiar in vitro and in vivo properties, at present approved for double fludarabine and alemtuzumab refractory chronic lymphocytic leukemia. Its efficacy in this subset of patients, who typically have an unfavorable prognosis, facilitated its use in different Phase II and III trials. Ofatumumab as single agent or combined with chemotherapeutic or biologic agents, led to sundry results in the setting of both previously treated or untreated patients. Its role in maintenance therapy is also under investigation. Further advances concerning ofatumumab administration as first line therapy in combination with chlorambucil, came recently from the COMPLEMENT 1 study. Results from this trial will open the door to new perspectives of its use in treatment-naïve patients. Ofatumumab was well tolerated in almost all the studies, with the main adverse events relating mostly to infusion reaction. Hematologic toxicity, especially neutropenia, was also common. A significant improvement in patients' quality of life was reported following ofatumumab treatment and this was mainly due to its effect on constitutional symptoms. Nevertheless, some concerns remain regarding the long-term efficacy of the drug in terms of response duration and survival. The real strength of this drug needs to be confirmed by further studies and direct comparative trials.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
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Sylvan SE, Skribek H, Norin S, Muhari O, Österborg A, Szekely L. Sensitivity of chronic lymphocytic leukemia cells to small targeted therapeutic molecules: An in vitro comparative study. Exp Hematol 2015; 44:38-49.e1. [PMID: 26325331 DOI: 10.1016/j.exphem.2015.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/18/2015] [Accepted: 08/21/2015] [Indexed: 10/23/2022]
Abstract
New drugs targeting important cellular signaling pathways are currently being developed for chronic lymphocytic leukemia (CLL). It is therefore of interest to analyze their in vitro killing capacity in manufacturer-independent, comparative experiments. We here report on the sensitivity of CLL cells to a panel of emerging targeted therapeutics using high-throughput screening based on an automated fluorescence digital scanning system. Fresh CLL cells from 42 patients with indolent or progressive CLL were cultured for 72 hours on microtiter plates in a unique primary cell culture medium. Antitumor effects of 31 small therapeutic molecules (and, as controls, 29 cytostatic agents) at equimolar concentration were compared in a fluorescence survival assay. In vitro sensitivity to each drug exhibited considerable interpatient variability. The highest mean direct killing was observed for one survivin inhibitor (YM-155), two bcl-2 inhibitors (ABT-199, ABT-737), and one selective CDK inhibitor (dinaciclib). Their killing capacity was, in contrast to most cytostatic agents, similarly high in refractory versus untreated CLL patients and was significantly higher on cells with the 17p deletion/TP53 mutation than on cells with other cytogenetic abnormalities (p = 0.02). Sensitivity of bone marrow and lymph node cells was highly correlated with that of blood cells. Even though direct killing may not be the only therapeutic effector function in vivo, results from this head-to-head comparison may help to identify drugs of particular interest for intensified clinical development.
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Affiliation(s)
- Sandra Eketorp Sylvan
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.
| | - Henriette Skribek
- Department of Microbiology, Tumor and Cell Biology and Center for Integrative Recognition in the Immune System, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Norin
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Orsolya Muhari
- Department of Microbiology, Tumor and Cell Biology and Center for Integrative Recognition in the Immune System, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Laszlo Szekely
- Department of Microbiology, Tumor and Cell Biology and Center for Integrative Recognition in the Immune System, Karolinska Institutet, Stockholm, Sweden
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18
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Cuesta-Mateos C, Loscertales J, Kreutzman A, Colom-Fernández B, Portero-Sáinz I, Pérez-Villar JJ, Terrón F, Muñoz-Calleja C. Preclinical activity of anti-CCR7 immunotherapy in patients with high-risk chronic lymphocytic leukemia. Cancer Immunol Immunother 2015; 64:665-76. [PMID: 25724841 PMCID: PMC11029146 DOI: 10.1007/s00262-015-1670-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 02/14/2015] [Indexed: 01/05/2023]
Abstract
Chronic lymphocytic leukemia (CLL) with deletions of the p53 locus on chromosome 17 and/or refractory to fludarabine chemoimmunotherapy remains a major clinical problem with few therapeutic options. Currently, these types of CLL are treated with approaches that do not target the p53 pathway, such as small molecules and monoclonal antibodies (mAb). We have previously postulated anti-CCR7 mAb therapy as a novel CLL treatment. In the present study, we evaluated the in vitro efficacy of anti-CCR7 mAb as a single agent in CLL patients with high-risk cytogenetics and/or refractory to fludarabine, by measuring CCR7 surface expression and complement-dependent cytotoxicity. Our results demonstrate that CCR7 is highly expressed in challenging and heavily treated CLL patients. In addition, the complement-mediated mechanism of action of this mAb effectively eradicates CLL cells while sparing subsets of T cells in these patients. Moreover, this mAb outperformed the activity of alemtuzumab, the mAb with the highest efficacy in these groups. Finally, in vitro activity was also demonstrated in patients with a disease refractory to both fludarabine and alemtuzumab, and patients harboring 11q22 deletion. Our results propose that anti-CCR7 mAb is an effective and promising future treatment in high-risk CLL.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Murine-Derived/pharmacology
- Genes, p53
- Humans
- Immunophenotyping
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Receptors, CCR7/antagonists & inhibitors
- Receptors, CCR7/biosynthesis
- Receptors, CCR7/genetics
- Receptors, CCR7/immunology
- Risk Factors
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Affiliation(s)
- Carlos Cuesta-Mateos
- Servicio de Inmunología, Departamento de Inmunología, Instituto de Investigación Sanitaria Hospital Universitario de La Princesa, C/Diego de León 62, 28006, Madrid, Spain,
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19
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20
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Österborg A, Wierda WG, Mayer J, Hess G, Hillmen P, Schetelig J, Schuh A, Smolej L, Beck C, Dreyfus B, Hellman A, Kozlowski P, Pfreundschuh M, Rizzi R, Spacek M, Phillips JL, Gupta IV, Williams V, Jewell RC, Nebot N, Lisby S, Dyer MJS. Ofatumumab retreatment and maintenance in fludarabine-refractory chronic lymphocytic leukaemia patients. Br J Haematol 2015; 170:40-9. [DOI: 10.1111/bjh.13380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/04/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Anders Österborg
- Department of Haematology; Karolinska University Hospital; Stockholm Sweden
| | - William G. Wierda
- The University of Texas; M.D. Anderson Cancer Center; Houston TX USA
- Cancer Therapy Research Center; San Antonio TX USA
| | - Jiří Mayer
- Department of Internal Medicine/Haemato-Oncology; Faculty Hospital Brno; Brno Czech Republic
| | - Georg Hess
- Johannes-Gutenberg-Universtitaer Mainz; Mainz Germany
| | | | | | | | - Lukáš Smolej
- Faculty of Medicine in Hradec Kralove; University Hospital and Charles University in Prague; Hradec Kralove Czech Republic
| | - Christian Beck
- Haematologisch-Onkologisches Institut; Moenchengladbach-Rheydt Germany
| | | | | | | | | | - Rita Rizzi
- Azienda Ospendaliero Universitaria Policlinico Consorziale; Bari Italy
| | | | | | | | | | | | | | | | - Martin J. S. Dyer
- Ernest and Helen Scott Haematological Research Institute; University of Leicester; Leicester UK
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21
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Österborg A, Jewell RC, Padmanabhan-Iyer S, Kipps TJ, Mayer J, Stilgenbauer S, Williams CD, Hellmann A, Furman RR, Robak T, Hillmen P, Trnêný M, Dyer MJS, Piotrowska M, Kozak T, Gupta IV, Phillips JL, Goldstein N, Struemper H, Losic N, Lisby S, Wierda WG. Ofatumumab monotherapy in fludarabine-refractory chronic lymphocytic leukemia: final results from a pivotal study. Haematologica 2015; 100:e311-4. [PMID: 25769539 DOI: 10.3324/haematol.2014.121459] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Anders Österborg
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Swami Padmanabhan-Iyer
- Cancer Therapy Research Center, San Antonio, TX, USA (formerly Roswell Park Cancer Institute, Buffalo, NY, USA)
| | | | - Jiří Mayer
- Faculty Hospital Brno, Dept of Internal Medicine/Hemato-Oncology, Czech Republic
| | | | - Cathy D Williams
- Center for Clinical Haematology, Nottingham University Hospitals, UK
| | | | - Richard R Furman
- Weill Cornell Medical College, Division of Hematology/Oncology, New York, NY, USA
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Poland
| | - Peter Hillmen
- St James' Institute of Oncology, St James' University Hospital, Leeds, UK
| | - Marek Trnêný
- First Faculty of Medicine, Charles University General Hospital, Prague, Czech Republic
| | - Martin J S Dyer
- The Ernest and Helen Scott Haematological Research Institute, University of Leicester, UK
| | | | - Tomas Kozak
- University Hospital Kralovske Vinohrady, Department of Clinical Hematology, Prague, Czech Republic
| | | | | | | | | | | | | | - William G Wierda
- The University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
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22
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Tam CS, Stilgenbauer S. How best to manage patients with chronic lymphocytic leuekmia with 17p deletion and/orTP53mutation? Leuk Lymphoma 2015; 56:587-93. [DOI: 10.3109/10428194.2015.1011641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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23
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Durot E, Michallet AS, Leprêtre S, Le QH, Leblond V, Delmer A. Platinum and high-dose cytarabine-based regimens are efficient in ultra high/high-risk chronic lymphocytic leukemia and Richter's syndrome: results of a French retrospective multicenter study. Eur J Haematol 2015; 95:160-7. [DOI: 10.1111/ejh.12474] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 01/04/2023]
Affiliation(s)
- Eric Durot
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
| | | | - Stéphane Leprêtre
- Département d'Hématologie, Unicancer; Centre Henri Becquerel; Rouen France
| | - Quoc-Hung Le
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
| | - Véronique Leblond
- AP-HP; Service d'Hématologie Clinique; Hôpital Pitié-Salpêtrière; Paris France
- UPMC Université Paris 06 GRC11-GRECHY; Paris France
| | - Alain Delmer
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
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24
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Bloor A, De Cock E, Hatswell AJ, Wasiak R, Elvidge J, Stapelkamp C, Hadjivassileva T, Haiderali A, Delgado J. Survival outcomes and treatment costs for patients with double-refractory chronic lymphocytic leukaemia (DR-CLL). Br J Haematol 2014; 169:449-52. [PMID: 25410960 DOI: 10.1111/bjh.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Adrian Bloor
- Department of Haematology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
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Innis-Shelton RD, Davis RS, Lamb L, Mineishi S. Paradigm shifts in the management of poor-risk chronic lymphocytic leukemia. Leuk Lymphoma 2014; 56:1626-35. [PMID: 25308292 DOI: 10.3109/10428194.2014.974041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
With the growing complexity of treatment options for chronic lymphocytic leukemia (CLL) and variables that influence the underlying biology of this disease, providing allogeneic stem cell transplant (alloSCT) to appropriate candidates poses a challenge for transplant physicians. Novel small molecule inhibitors hold unprecedented promise for poor-risk subgroups, which will likely alter decision-making and referral patterns for transplant. In this review, we analyze what is known and may still remain true about indications for transplant based on outcomes reported in the literature recently and over the last decade.
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Affiliation(s)
- Racquel D Innis-Shelton
- Division of Hematology and Oncology, BMT and CT Program, Department of Internal Medicine, UAB Hosptial, University of Alabama at Birmingham Comprehensive Cancer Center , Birmingham, AL , USA
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Oberic L, Vaillant W, Hebraud B, Recher C, Suc E, Houyau P, Laurent G, Ysebaert L. Clinical activity of a new regimen combining gemcitabine and alemtuzumab in high-risk relapsed/refractory chronic lymphocytic leukemia patients. Eur J Haematol 2014; 94:37-42. [PMID: 24939411 DOI: 10.1111/ejh.12391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2014] [Indexed: 11/30/2022]
Abstract
Optimal treatment strategies are lacking in relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). Gemcitabine has shown activity and acceptable safety profile in B-cell lymphomas. We present a retrospective case review of gemcitabine and alemtuzumab, every 21 d (for up to six courses) in 27 community-based patients with high-risk R/R CLL. Median age was 70 yr (44-83 yr), 55% patients had Binet stage C, deletion 17p (del(17p)) and/or deletion 11q (del(11q)) were found in 65% and 27%, bulky disease in 55.5%, and fludarabine-refractoriness in 48% of cases, respectively. Overall response rate was 63% (29.6% clinical CR and 33.4% PR). At a median follow-up of 31 months, median PFS and OS were 15.4 and 24 months. In multivariate analysis, median OS is influenced by prior lines of treatment = 3 and bulky disease. Combination of alemtuzumab and gemcitabine appears to be an active, easy to administrate treatment in routine practice, high-risk R/R CLL patients.
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Affiliation(s)
- Lucie Oberic
- Department of Hematology, Purpan University Hospital, Toulouse cedex, France
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27
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Cuneo A, Cavazzini F, Ciccone M, Daghia G, Sofritti O, Saccenti E, Negrini M, Rigolin GM. Modern treatment in chronic lymphocytic leukemia: impact on survival and efficacy in high-risk subgroups. Cancer Med 2014; 3:555-64. [PMID: 24648042 PMCID: PMC4101746 DOI: 10.1002/cam4.226] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/08/2014] [Accepted: 02/13/2014] [Indexed: 12/15/2022] Open
Abstract
Treatment of chronic lymphocytic leukemia (CLL) has dramatically changed over the last years, with significant improvement in overall survival (OS) and increased efficacy in genetically defined "high-risk" disease. Besides prospective clinical trials usually enrolling young and fit patients, retrospective studies were performed comparing the outcome of patients belonging to different age groups and showing longer survival in patients diagnosed in the most recent periods. In patients younger than 70 years the 10-year relative survival was 43-53% in the 1980s as compared with 59-63% in the 2000s. Likewise, the 10-year relative survival in patients >70 years was 22-42% in the 1980s and 46-55% in the 2000s. Improved outcome derived in part by the introduction of effective regimens in genetically defined "high-risk" disease (i.e., 17p-, 11q-, TP53, NOTCH1, SF3B1 mutations), especially in the younger and/or fit patients. The unfavorable prognostic significance of 11q- was overcome by chemoimmunotherapy. High-dose steroids with anti-CD52 appeared to improve the response rate in 17p-/TP53 mutated cases and allogeneic transplantation achieved prolonged disease control irrespective of high-risk disease. Further improvement is being generated by the new anti-CD20 obinutuzumab in the elderly and by mechanism-based treatment using kinase-targeting agents or anti-BCL2 molecules yielding high-response rate and impressive progression-free survival in the chemorefractory setting as well as in previously untreated patients.
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MESH Headings
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols
- Disease-Free Survival
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/radiotherapy
- Male
- Mutation
- Prognosis
- Proto-Oncogene Proteins c-bcl-2/genetics
- Randomized Controlled Trials as Topic
- Retrospective Studies
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
- Antonio Cuneo
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Francesco Cavazzini
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Maria Ciccone
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Giulia Daghia
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Olga Sofritti
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Elena Saccenti
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
| | - Massimo Negrini
- Laboratory for Technologies of Advanced Therapies (LTTA) and Department of Morphology, Surgery and Experimental Medicine, University of FerraraFerrara, Italy
| | - Gian Matteo Rigolin
- Hematology Section, Department of Medical Sciences, University of Ferrara, University Hospital Arcispedale S. AnnaFerrara, Italy
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28
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Eketorp Sylvan S, Lundin J, Ipek M, Palma M, Karlsson C, Hansson L. Alemtuzumab (anti-CD52 monoclonal antibody) as single-agent therapy in patients with relapsed/refractory chronic lymphocytic leukaemia (CLL)—a single region experience on consecutive patients. Ann Hematol 2014; 93:1725-33. [DOI: 10.1007/s00277-014-2105-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
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29
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Eketorp Sylvan S, Hansson L, Karlsson C, Norin S, Lundin J, Osterborg A. Outcomes of patients with fludarabine-refractory chronic lymphocytic leukemia: a population-based study from a well-defined geographic region. Leuk Lymphoma 2014; 55:1774-80. [PMID: 24237446 DOI: 10.3109/10428194.2013.827786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with fludarabine-refractory (FR) chronic lymphocytic leukemia (CLL) receive novel agents in pivotal, non-randomised phase-2 trials. Understanding outcome of FR-CLL in health-care may provide important contextual information. Records from 1301 patients (Stockholm-Cancer-Registry 1991-2010) identified 92 FR-patients; bulky lymph-nodes (BFR-group), double-refractory (DR-group), or Others'-group for outcome-analysis. Median age was 69 years 67% had Rai-stage III/IV with median 3 prior therapies. Overall response-rate was 20%; significantly lower in BFR (8%, p = 0.01) and DR (20%, p = 0.01) than in 'Others' (31%). Time-to-treatment-failure (months) was significantly longer in 'Others' (9.2) than in BFR/DR (5.3/4.4) (p < 0.01) and significantly longer (p < 0.05) in antibody-treated patients (9.1) compared to other regimens (5.2). Early-death occurred in 5%, ≥ grade III-infections in 20%. Median overall-survival (OS) was 18 months; 29 in BFR vs. 13 in DR (p = 0.054). Male sex was the only prognostic factor on OS (p = 0.01, HR 2.2, multivariate-Cox-regression). Our results, without external referrals, facilitate interpretation of non-randomised trials/novel drugs in advanced-stage-CLL.
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Affiliation(s)
- Sandra Eketorp Sylvan
- Departments of Hematology and Oncology, Karolinska University Hospital , Stockholm , Sweden
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Mehta RS, Di Stasi A, Hosing C, Shah N, Rezvani K, Alousi A, O'Brien S, Wierda W, Keating M, Shpall EJ. Lenalidomide-induced graft-vs.-Leukemia effect in a patient with chronic lymphocytic leukemia who relapsed after allogeneic stem cell transplant. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:e105-9. [PMID: 24502832 DOI: 10.1016/j.clml.2013.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 12/12/2013] [Accepted: 12/23/2013] [Indexed: 01/13/2023]
Affiliation(s)
- Rohtesh S Mehta
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Antonio Di Stasi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wierda
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Keating
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX
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Tolley K, Goad C, Yi Y, Maroudas P, Haiderali A, Thompson G. Utility elicitation study in the UK general public for late-stage chronic lymphocytic leukaemia. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:749-59. [PMID: 22941034 DOI: 10.1007/s10198-012-0419-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 07/30/2012] [Indexed: 05/04/2023]
Abstract
OBJECTIVES In the United Kingdom (UK), chronic lymphocytic leukaemia (CLL) makes up 40 % of all leukaemias in patients over 65 years. The study objective was to obtain societal preferences in the UK for "progression-free" and "progressive" states of late-stage CLL, refractory to current first and second line regimens. Preferences were also obtained for selected treatment-related adverse events (AEs). METHODS A utility elicitation study, using the time trade-off (TTO) method, was conducted by face-to-face interviews with 110 subjects for a baseline disease state (before treatment), three primary disease states [progression-free survival (PFS) and treatment responder, PFS and treatment non-responder and disease progression], and 4 AE sub-states (PFS responder with thrombocytopenia, neutropenia, and infection, and PFS non-responder with infection). TTO scores were converted into utility values, and disutilities were calculated for AEs. Visual analogue scale (VAS) scores were obtained. RESULTS The primary disease state mean TTO utility scores were: baseline: 0.549; PFS response: 0.671; PFS non-response: 0.394; and progression: 0.214. The mean TTO utility (disutility) scores for the AEs were: PFS response with thrombocytopenia, 0.563 (-0.108), neutropenia, 0.508 (-0.163), and infection, 0.476 (-0.195); PFS non-response with infection, 0.333 (-0.061). The VAS results were in line with the TTO results. CONCLUSIONS The utility was higher for the PFS state than baseline, but decreased below baseline in non-response and disease progression states. AEs had an impact on utility within the PFS response state. The severe infection AE had a greater impact on utilities for the responding to treatment state compared to the non-responder state.
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Cuthill K, Devereux S. How I treat patients with relapsed chronic lymphocytic leukaemia. Br J Haematol 2013; 163:423-35. [DOI: 10.1111/bjh.12549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/29/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Kirsty Cuthill
- Department of Haematological Medicine; Kings College; London UK
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Tumor protein p53 (TP53) testing and Li-Fraumeni syndrome : current status of clinical applications and future directions. Mol Diagn Ther 2013; 17:31-47. [PMID: 23355100 DOI: 10.1007/s40291-013-0020-0] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Prevalent as an acquired abnormality in cancer, the role of tumor protein p53 (TP53) as a germline mutation continues to evolve. The clinical impact of a germline TP53 mutation is often dramatic and affects the full life course, with a propensity to develop rare tumors in childhood and multiple common cancers of unexpectedly early onset in adulthood. In this article, we review the clinical relevance of germline mutations in the TP53 tumor suppressor gene to current healthcare practice, including the optimal ways to identify patients with Li-Fraumeni syndrome (LFS), to recognize the core cancers associated with LFS, and to develop strategies for early detection of LFS-associated tumors. Several TP53-targeted approaches to improve outcomes in LFS patients are also reviewed. A case report is used to highlight special TP53 testing dilemmas and unique challenges associated with genetic testing decisions in the current age of rapidly advancing genomic technologies.
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Tam CS, Keating MJ. Selection of rituximab dosage in chronic lymphocytic leukemia: where is the evidence? Leuk Lymphoma 2013; 54:934-9. [PMID: 22966877 DOI: 10.3109/10428194.2012.728595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rituximab prolongs survival in many CD20-expressing B- lymphoid malignancies. In non-Hodgkin lymphoma (NHL), a large number of clinical studies have established the 375 mg/m(2) dose of rituximab as standard. In chronic lymphocytic leukemia (CLL), response rates to single-agent rituximab at the NHL dose were low, but the use of higher doses or more frequent dosing have led to improved response rates, suggesting that a higher dose may be required. This led to the empiric decision to adopt rituximab at 500 mg/m(2) in combination with fludarabine and cyclophosphamide (FC) in phase II and III trials in CLL. The final result was the approval of rituximab at 500 mg/m(2) for treatment of CLL, in combination with FC. There is, however, preclinical evidence that full saturation of CD20 molecules may not be required to achieve chemosensitization in cancer cells, and it remains possible that the approved dose of 500 mg/m(2) is higher than what is required to achieve maximal in vivo synergy. Nevertheless, all of the randomized evidence for superiority of rituximab plus chemotherapy over chemotherapy alone comes from studies using the 500 mg/m(2) dose.
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Affiliation(s)
- Constantine S Tam
- Haematology Department, Peter MacCallum Cancer Centre, St Andrew's Place, East Melbourne, Victoria, Australia.
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Fonte E, Apollonio B, Scarfò L, Ranghetti P, Fazi C, Ghia P, Caligaris-Cappio F, Muzio M. In vitro sensitivity of CLL cells to fludarabine may be modulated by the stimulation of Toll-like receptors. Clin Cancer Res 2012; 19:367-79. [PMID: 23224401 DOI: 10.1158/1078-0432.ccr-12-1922] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The emerging role of Toll-like receptors (TLR) in the pathogenesis of chronic lymphocytic leukemia (CLL) led us to ask whether TLR stimulation may protect CLL cells from drug-induced apoptosis. EXPERIMENTAL DESIGN We cultured in vitro malignant B cells freshly isolated from 44 patients with CLLs in the presence or the absence of different concentrations of fludarabine before or after 24-hour TLR stimulation with specific ligands and evaluated cell viability, apoptosis, and molecular pathways involved. RESULTS Heterogeneity was observed among samples. In leukemic cells from patients bearing adverse prognostic factors, TLR stimulation caused a significant increase of protection to fludarabine treatment, whereas this did not occur in the cells from patients with good prognosis. To identify novel molecular mechanisms accounting for the dichotomy of response between the two groups of patients, we conducted an apoptosis gene expression profile on leukemic cells either unstimulated or stimulated with TLR9 ligand. Strikingly, TLR9 stimulation specifically upregulated the expression of lymphotoxin-α in cells where an increased protection to fludarabine treatment was observed. Also, the expression of miR-155-3p was significantly increased after stimulation of distinct TLR in cells where fludarabine treatment was less effective. CONCLUSIONS These results suggest that at least in a proportion of patients, in vitro sensitivity to fludarabine may be modulated by the stimulation of TLR, likely mimicking microenvironmental signals occurring in vivo.
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Affiliation(s)
- Eleonora Fonte
- San Raffaele Scientific Institute, Division of Molecular Oncology; Università Vita-Salute San Raffaele, Via Olgettina 58, Milan, Italy
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Vannata B, Innocenti I, Autore F, Sorà F, Chiusolo P, Leone G, Sica S, Laurenti L. High-dose glucocorticoids plus Ofatumumab in fludarabine/alemtuzumab-resistant B-cell chronic lymphocytic leukemia. Am J Hematol 2012; 87:E133. [PMID: 23115113 DOI: 10.1002/ajh.23349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 09/21/2012] [Accepted: 09/28/2012] [Indexed: 01/03/2023]
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Abstract
Infectious complications have been known to be a major cause of morbidity and mortality in Chronic Lymphocytic Leukemia (CLL) patients who are prone to infections because of both the humoral immunodepression inherent to the hematologic disease and to the immunosuppression related to the therapy. The majority of infections in CLL patients treated with alkilating agents is of bacterial origin. The immunodeficiency and natural infectious history of alkylator-resistant, corticosteroid-treated patients appears to have changed with the administration of purine analogs, which has been complicated by very severe and unusual infections and also more viral infections due to sustained reduction of CD4-positive T lymphocytes. The subsequent introduction of monoclonal antibodies in therapies, in particular alemtuzumab, further increased the immunodepression, increasing also infections which appeared more often in patients with recurrent neutropenia due to chemotherapy cycles.Epidemiological data regarding fungal infections in lymphoproliferative disorders are scarce. Italian SEIFEM group in a retrospective multicentre study regarding CLL patients reported an incidence of mycoses 0.5%; however, chronic lymphoproliferative disorders emerged as second haematological underlying disease after acute leukemia in a French study on aspergillosis; in particular CLL with aspergillosis accounted for a third of these chronic lymphoproliferative diseases presenting mould infection.
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Veliz M, Pinilla-Ibarz J. Treatment of relapsed or refractory chronic lymphocytic leukemia. Cancer Control 2012; 19:37-53. [PMID: 22143061 DOI: 10.1177/107327481201900105] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent advances in the treatment of chronic lymphocytic leukemia (CLL) have moved beyond the traditional use of alkylating agents and purine analogs into regimens combining these two chemotherapy classes with monoclonal antibodies. METHODS This article reviews treatments options for patients with relapsed or refractory CLL. RESULTS Several studies have investigated novel agents in treating patients with 17p deletion, TP53 mutation, and fludarabine-refractory CLL, as well as patients with suboptimal response to intense treatment. These investigational agents include rituximab, alemtuzumab, ofatumumab, bendamustine, high-dose methylprednisolone, lenalidomide, lumiliximab, cyclin-dependent kinase inhibitors, small modular immunopharmaceuticals, Bcl-2 inhibitors, and histone deacetylase inhibitors. While these newer drugs and combination therapies have shown promise as treatment options for CLL, additional studies are needed to determine the immunosuppression, toxicities, and infections associated with their use. CONCLUSIONS Despite improvement in initial overall response rates, most patients relapse and require further treatment. CLL remains incurable with standard therapies due to development of disease refractoriness. As such, novel approaches such as those noted above warrant continued research to improve outcomes for patients with CLL.
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Affiliation(s)
- Marays Veliz
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Wendtner CM, Hillmen P, Mahadevan D, Bühler A, Uharek L, Coutré S, Frankfurt O, Bloor A, Bosch F, Furman RR, Kimby E, Gribben JG, Gobbi M, Dreisbach L, Hurd DD, Sekeres MA, Ferrajoli A, Shah S, Zhang J, Moutouh-de Parseval L, Hallek M, Heerema NA, Stilgenbauer S, Chanan-Khan AA. Final results of a multicenter phase 1 study of lenalidomide in patients with relapsed or refractory chronic lymphocytic leukemia. Leuk Lymphoma 2011; 53:417-23. [PMID: 21879809 DOI: 10.3109/10428194.2011.618232] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Based on clinical activity in phase 2 studies, lenalidomide was evaluated in a phase 2/3 study in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). Following tumor lysis syndrome (TLS) complications, the protocol was amended to a phase 1 study to identify the maximum tolerated dose-escalation level (MTDEL). Fifty-two heavily pretreated patients, 69% with bulky disease and 48% with high-risk genomic abnormalities, initiated lenalidomide at 2.5 mg/day, with dose escalation until the MTDEL or the maximum assigned dose was attained. Lenalidomide was safely titrated to 20 mg/day; the MTDEL was not reached. Most common grade 3-4 adverse events were neutropenia and thrombocytopenia; TLS was mild and rare. The low starting dose and conservative dose escalation strategy resulted in six partial responders and 30 patients obtaining stable disease. In summary, lenalidomide 2.5 mg/day is a safe starting dose that can be titrated up to 20 mg/day in patients with CLL.
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Affiliation(s)
- Clemens-Martin Wendtner
- Department I of Internal Medicine, Center of Integrated Oncology (CIO), CECAD, University of Cologne, Cologne, Germany.
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Nightingale G. Ofatumumab: a novel anti-CD20 monoclonal antibody for treatment of refractory chronic lymphocytic leukemia. Ann Pharmacother 2011; 45:1248-55. [PMID: 21896924 DOI: 10.1345/aph.1p780] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To present the current clinical evidence on ofatumumab for use in refractory chronic lymphocytic leukemia (CLL). DATA SOURCES A literature search was performed using MEDLINE and PubMed (both 1966-May 2011), as well as the American Society of Hematology abstracts (2000-May 2011), using the primary search terms ofatumumab and HuMax-CD20. STUDY SELECTION AND DATA EXTRACTION Clinical studies and abstracts available in the English language, describing the pharmacology, pharmacokinetics, clinical activity, and safety of ofatumumab in CLL were included in this review. DATA SYNTHESIS Ofatumumab is a human immunoglobulin monoclonal antibody that binds to B-lymphocytes expressing CD-20 cell surface antigens. Ofatumumab was granted accelerated approval by the Food and Drug Administration in October 2009 for the treatment of CLL refractory to fludarabine and alemtuzumab. A Phase 1/2 trial has established the safety and tolerability of single-agent ofatumumab at an initial dose of 300 mg intravenously on week 1, followed by 2000 mg once weekly for 7 doses (weeks 2-8), followed by 2000 mg once every 4 weeks for 4 doses (weeks 9-12), for a total of 12 doses. The final analysis of a pivotal international multicenter trial has shown promising activity in patients with CLL refractory to fludarabine and alemtuzumab, demonstrating overall response rates of 44-51%, with prolonged progression-free and overall survival. Ofatumumab activity has also been shown in a variety of other malignant and nonmalignant conditions, including non-Hodgkin lymphoma, rheumatoid arthritis, and multiple sclerosis. The most common adverse effect is grade 1 and 2 infusion reactions. Other adverse effects include infection, neutropenia, anemia, rash, fever, and diarrhea. CONCLUSIONS Clinical evidence suggests that ofatumumab is an effective agent in patients with CLL refractory to fludarabine and alemtuzumab. Data are awaited comparing ofatumumab to other salvage regimens. Until results of head-to-head trials are conducted comparing ofatumumab to existing regimens, it cannot be said whether ofatumumab is more efficacious or tolerable than currently available therapies.
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Affiliation(s)
- Ginah Nightingale
- Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA.
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Reagan JL, Castillo JJ. Ofatumumab for newly diagnosed and relapsed/refractory chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2011; 11:151-60. [PMID: 21342032 DOI: 10.1586/era.10.223] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal antibodies have become an increasingly utilized treatment option for many hematological malignancies, including chronic lymphocytic leukemia (CLL). Ofatumumab is a second-generation fully human anti-CD20 monoclonal antibody that binds to the small extracellular loop of CD20, thereby producing complement-dependent cell lysis and antibody-mediated cell cytotoxicity in cells expressing CD20. Ofatumumab has shown efficacy in the treatment for relapsed or refractory CLL. This success has resulted in the recent US FDA approval of ofatumumab for the treatment of CLL in patients who are refractory to fludarabine and alemtuzumab-based regimens. Major side effects of ofatumumab include infusion reactions, neutropenia and increased risk for infection. This article provides an overview of the current data supporting the use of ofatumumab for CLL and projects the future role of ofatumumab as monotherapy and combination therapy.
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Affiliation(s)
- John L Reagan
- Division of Hematology and Oncology, The Warren Alpert Medical School of Brown University, The Miriam Hospital, Providence, RI 02906, USA
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Ofatumumab is active in patients with fludarabine-refractory CLL irrespective of prior rituximab: results from the phase 2 international study. Blood 2011; 118:5126-9. [PMID: 21856867 DOI: 10.1182/blood-2011-04-348656] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Ofatumumab, the human CD20 monoclonal antibody that binds a distinct epitope from rituximab, has demonstrated clinical benefit as monotherapy for patients with chronic lymphocytic leukemia refractory to fludarabine and alemtuzumab (FA-ref) and patients refractory to fludarabine with bulky (> 5 cm) lymph nodes (BF-ref). To potentially gain insight into outcomes in patients previously treated with or refractory to rituximab, we performed an ad hoc retrospective analysis in the final 96 FA-ref and 111 BF-ref patients. There were 117 patients previously treated with rituximab (98 rituximab-refractory); 89 patients were rituximab-naive. For rituximab-treated, rituximab-refractory, and rituximab-naive patients, overall response rate was 43%, 44%, and 53%; median progression-free survival was 5.3, 5.5, and 5.6 months; and median overall survival was 15.5, 15.5, and 20.2 months. There were no significant differences in ofatumumab-related infusion reactions, or hematologic or infectious adverse events between subgroups. In summary, ofatumumab monotherapy was effective and well tolerated in patients with fludarabine-refractory chronic lymphocytic leukemia, including in patients with previous rituximab exposure. This trial was registered at www.clinicaltrials.gov as #NCT00349349.
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Andritsos LA, Grever MR. Salvage therapy for relapsed chronic lymphocytic leukemia. Expert Rev Hematol 2011; 4:199-212. [PMID: 21495929 DOI: 10.1586/ehm.11.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic lymphocytic leukemia is a common hematologic malignancy with a highly variable clinical course. While the median age at diagnosis is 72 years of age and fewer than 10% of patients are diagnosed before the age of 60 years, the majority of patients who require therapy will ultimately relapse. Advances in upfront therapy and supportive care have dramatically improved initial responses compared with traditional akylator-based chemotherapy. However, comparable results are not generally observed in the salvage setting. Careful planning that takes into account the duration of the initial response, patient age and/or comorbidities, and cytogenetic and molecular profiles are critical for the successful management of patients with relapsed chronic lymphocytic leukemia.
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Hoyle M, Crathorne L, Garside R, Hyde C. Ofatumumab for the treatment of chronic lymphocytic leukaemia in patients who are refractory to fludarabine and alemtuzumab: a critique of the submission from GSK. Health Technol Assess 2011. [DOI: 10.3310/hta15suppl1-07] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This paper presents a summary of the evidence review group (ERG) report into the clinical effectiveness and cost-effectiveness of ofatumumab for the treatment of refractory chronic lymphocytic leukaemia (CLL), based upon the manufacturer’s submission (MS) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal process. The submitted clinical evidence included one study: a non-randomised, single-arm study. Two other studies were identified but both were non-comparative and provided evidence for therapies other than ofatumumab. For this reason these studies were not discussed in full in the main body of the submission. In the Hx-CD20-406 study, the overall response rate was 58% (99% confidence interval 40% to 74%, p < 0.001). Complete resolution of constitutional symptoms and improved performance status occurred in 57% of patients. Median progression-free survival (PFS) and overall survival (OS) times were 5.7 and 13.7 months, respectively. The most common adverse events during treatment were infusion reactions and infections, which were primarily grade 1 or 2 events. The MS concluded that ofatumumab provides a new, effective and well-tolerated therapy for patients with CLL who are refractory to both fludarabine and alemtuzumab [double refractory (DR)]. The ERG undertook a critical appraisal of the submission. The ERG had a number of concerns regarding the manufacturer’s estimates of effectiveness based on evidence from a single-arm, non-randomised study. An ‘area-under-the-curve’ or ‘partitioned-survival’ model was used to project expected clinical and economic outcomes for patients with DR CLL who were assumed to receive ofatumumab or best supportive care (BSC). The model had a three-state structure: ‘alive pre-progression’, ‘alive post progression’ and ‘dead’. Overall, the modelling approach is reasonable given the limited evidence available for the drug in the patient population under review. However, a number of uncertainties were identified in the economic evaluation; for example, the BSC arm used data from patients in the Hx-CD20-406 study who did not respond to ofatumumab treatment – ‘non-responders’ – and the ofatumumab arm used data from all of those treated in the Hx-CD20-406 study. Further uncertainty arose regarding the choice of utilities, the omission of 17p and 11q chromosomal deletions as factors in the Cox proportional hazards models for PFS and OS, and the omission of the costs of drugs in progressive disease. It was felt that these factors biased cost-effectiveness in favour of ofatumumab. When revisions were made to the assumptions in the model based on the ERG’s review of the published and submitted evidence, the revised base-case incremental cost-effectiveness ratio for ofatumumab increased to £81,500 per quality-adjusted life-year. The final appraisal determination was issued by NICE in September 2010 (www.nice.org.uk/nicemedia/live/12264/50758/50758.pdf).
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Affiliation(s)
- M Hoyle
- PenTAG, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK
| | - L Crathorne
- PenTAG, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK
| | - R Garside
- PenTAG, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK
| | - C Hyde
- PenTAG, Peninsula College of Medicine and Dentistry, Universities of Exeter and Plymouth, UK
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Khouri IF, Bassett R, Poindexter N, O'Brien S, Bueso-Ramos CE, Hsu Y, Ferrajoli A, Keating MJ, Champlin R, Fernandez-Vina M. Nonmyeloablative allogeneic stem cell transplantation in relapsed/refractory chronic lymphocytic leukemia: long-term follow-up, prognostic factors, and effect of human leukocyte histocompatibility antigen subtype on outcome. Cancer 2011; 117:4679-88. [PMID: 21455998 DOI: 10.1002/cncr.26091] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Revised: 01/23/2011] [Accepted: 02/10/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of nonmyeloablative allogeneic stem cell transplantation (NST) in the treatment of chronic lymphocytic leukemia (CLL) is not well established. The authors report on long-term experience with NST in relapsed/refractory CLL and define prognostic factors associated with outcome. METHODS The authors reviewed the outcome of 86 patients with relapsed/relapsed CLL enrolled in sequential NST protocols. RESULTS The median patient age was 58 years. Patients were heavily pretreated before transplantation, and 43 required immunomanipulation after NST for persistent or recurrent disease. Immunomanipulation included withdrawal of immunosuppression, rituximab, and step-wise donor lymphocyte infusions. Of 43 patients receiving immunomanipulation, 20 (47%) experienced a complete remission. Patients with human leukocyte antigen (HLA) genotype A1(+) /A2(-) /B44(-) were more likely to experience a complete remission (P = .0009), with rates of 9%, 36%, 50%, and 91%, respectively, for 0, 1, 2, and 3 of these HLA factors. This resulted in significant improvement in progression-free-survival rates of 68.2% at 5 years for patients with all 3 HLA factors. Overall, the estimated 5-year survival rate was 51%. In a multivariate model, a CD4 count of <100/mm(3) and a below normal serum immunoglobulin G level at study entry were associated with a short survival duration (P < .0001). CONCLUSIONS These results confirm the potential cure of relapsed/refractory CLL with NST and provide the first evidence that immunoglobulin G and CD4 levels are predictive of overall survival after NST in CLL and that human leukocyte antigen alleles predict response to immunomanipulation.
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Affiliation(s)
- Issa F Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, USA.
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Smolej L. How I treat elderly or comorbid patients with chronic lymphocytic leukemia. ACTA MEDICA (HRADEC KRÁLOVÉ) 2011; 53:213-20. [PMID: 21400979 DOI: 10.14712/18059694.2016.79] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Treatment of chronic lymphocytic leukemia (CLL) has recently undergone several major changes. Most importantly, large randomized trials (CLL-8 in first line and REACH in relapse) clearly demonstrated superiority of chemoimmunotherapy consisting of fludarabine, cyclophosphamide and rituximab (FCR) over fludarabine and cyclophosphamide (FC) alone, thus establishing FCR regimen as the new gold standard in younger and physically fit patients. However, management of elderly and/or comorbid patients is still a challenging task because they cannot be treated with agressive approaches due to high risk of unacceptable toxicity. To date, no randomized trials in this patient population have improved therapeutic results over chlorambucil; therefore, this agent remains the backbone of treatment against which the new protocols should be tested. When deciding about the intensity of treatment, performance status, biological age and number as well as severity of comorbidities should be taken into account. Emerging treatment concepts for elderly/comorbid patients include combination of chlorambucil with monoclonal antibodies (rituximab, ofatumumab, GA-101), fludarabine-based regimens in reduced doses or protocols based on bendamustine and lenalidomide. Combination of high-dose steroids with rituximab represent a promising option in relapsed/refractory CLL; however, infectious toxicity remains a serious issue. Finally, ofatumumab monotherapy appears to be a safe and effective therapy for heavily pretreated patients with CLL. This article reviews the current and future possibilities in the treatment of elderly and comorbid patients with CLL.
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Affiliation(s)
- Lukás Smolej
- 2nd Department of Medicine, Charles University in Prague, Faculty of Medicine and University Hospital Hradec Králové, Czech Republic.
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Nabhan C, Kay NE. The emerging role of ofatumumab in the treatment of chronic lymphocytic leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2011; 5:45-53. [PMID: 21499555 PMCID: PMC3076040 DOI: 10.4137/cmo.s4087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The treatment of chronic lymphocytic leukemia (CLL) has evolved over the past decade. Our better understanding of disease biology and risk stratification has allowed delivering more effective therapies. In fact, front-line chemoimmunotherapy has demonstrated improvement in overall survival when compared to chemotherapy in randomized studies. Yet, treatment of relapsed CLL remains challenging and few agents are effective in that setting. Ofatumumab (Ofa) is a humanized monoclonal antibody targeted against CD20 with demonstrable activity in rituximab-resistant CLL cell lines. This agent was recently approved for the treatment of relapsed/refractory CLL patients who have failed fludarabine and alemtuzumab. In this review, we provide a historical perspective on approaches to CLL as front-line and in the relapsed setting. We further summarize novel anti-CD20 antibodies with specific emphasis on ofa. We review studies that led to ofatumumab's approval including pre-clinical data, trials using ofa in combination therapies, and adverse events/toxicities reported with this agent.
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Affiliation(s)
- Chadi Nabhan
- Oncology Specialists, S. C., Department of Medicine, Division of Hematology/Oncology at Advocate Lutheran General Hospital, Park Ridge, IL 60068, USA
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Brown JR. The treatment of relapsed refractory chronic lymphocytic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:110-118. [PMID: 22160021 DOI: 10.1182/asheducation-2011.1.110] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Despite the widespread use of highly effective chemoimmunotherapy (CIT), fludarabine-refractory chronic lymphocytic leukemia (CLL) remains a challenging clinical problem associated with poor overall survival (OS). The traditional definition, which includes those patients with no response or relapse within 6 months of fludarabine, is evolving with the recognition that even patients with longer remissions of up to several years after CIT have poor subsequent treatment response and survival. Approved therapeutic options for these patients remain limited, and the goal of therapy for physically fit patients is often to achieve adequate cytoreduction to proceed to allogeneic stem cell transplantation (alloSCT). Fortunately, several novel targeted therapeutics in clinical trials hold promise of significant benefit for this patient population. This review discusses the activity of available and novel therapeutics in fludarabine-refractory or fludarabine-resistant CLL as well as recently updated data on alloSCT in CLL.
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Affiliation(s)
- Jennifer R Brown
- Harvard Medical School and CLL Center, Dana-Farber Cancer Institute, Boston, MA, USA.
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