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Lee CH, Wu YY, Huang TC, Lin C, Zou YF, Cheng JC, Chen PH, Jhou HJ, Ho CL. Maintenance therapy for chronic lymphocytic leukaemia. Cochrane Database Syst Rev 2024; 1:CD013474. [PMID: 38174814 PMCID: PMC10765471 DOI: 10.1002/14651858.cd013474.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common lymphoproliferative disease in adults and currently remains incurable. As the progression-free period shortens after each successive treatment, strategies such as maintenance therapy are needed to improve the degree and duration of response to previous therapies. Monoclonal antibodies, immunomodulatory agents, and targeted therapies are among the available options for maintenance therapy. People with CLL who achieve remission after previous therapy may choose to undergo medical observation or maintenance therapy to deepen the response. Even though there is widespread use of therapeutic maintenance agents, the benefits and harms of these treatments are still uncertain. OBJECTIVES To assess the effects and safety of maintenance therapy, including anti-CD20 monoclonal antibody, immunomodulatory drug therapy, anti-CD52 monoclonal antibody, Bruton tyrosine kinase inhibitor, and B-cell lymphoma-2 tyrosine kinase inhibitor, for individuals with CLL. SEARCH METHODS We conducted a comprehensive literature search for randomised controlled trials (RCTs) with no language or publication status restrictions. We searched CENTRAL, MEDLINE, Embase, and three trials registers in January 2022 together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA We included RCTs with prospective identification of participants. We excluded cluster-randomised trials, cross-over trial designs, and non-randomised studies. We included studies comparing maintenance therapies with placebo/observation or head-to-head comparisons. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We assessed risk of bias in the included studies using Cochrane's RoB 1 tool for RCTs. We rated the certainty of evidence for the following outcomes using the GRADE approach: overall survival (OS), health-related quality of life (HRQoL), grade 3 and 4 adverse events (AEs), progression-free survival (PFS), treatment-related mortality (TRM), treatment discontinuation (TD), and all adverse events (AEs). MAIN RESULTS We identified 11 RCTs (2393 participants) that met the inclusion criteria, including seven trials comparing anti-CD20 monoclonal antibodies (mAbs) (rituximab or ofatumumab) with observation in 1679 participants; three trials comparing immunomodulatory drug (lenalidomide) with placebo/observation in 693 participants; and one trial comparing anti-CD 52 mAbs (alemtuzumab) with observation in 21 participants. No comparisons of novel small molecular inhibitors were found. The median age of participants was 54.1 to 71.7 years; 59.5% were males. The type of previous induction treatment, severity of disease, and baseline stage varied among the studies. Five trials included early-stage symptomatic patients, and three trials included advanced-stage patients (Rai stage III/IV or Binet stage B/C). Six trials reported a frequent occurrence of cytogenic aberrations at baseline (69.7% to 80.1%). The median follow-up duration was 12.4 to 73 months. The risk of selection bias in the included studies was unclear. We assessed overall risk of performance bias and detection bias as low risk for objective outcomes and high risk for subjective outcomes. Overall risk of attrition bias, reporting bias, and other bias was low. Anti-CD20 monoclonal antibodies (mAbs): rituximab or ofatumumab maintenance versus observation Anti-CD20 mAbs maintenance likely results in little to no difference in OS (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.73 to 1.20; 1152 participants; 3 studies; moderate-certainty evidence) and likely increases PFS significantly (HR 0.61, 95% CI 0.50 to 0.73; 1255 participants; 5 studies; moderate-certainty evidence) compared to observation alone. Anti-CD20 mAbs may result in: an increase in grade 3/4 AEs (rate ratio 1.34, 95% CI 1.06 to 1.71; 1284 participants; 5 studies; low-certainty evidence); little to no difference in TRM (risk ratio 0.82, 95% CI 0.39 to 1.71; 1189 participants; 4 studies; low-certainty evidence); a slight reduction to no difference in TD (risk ratio 0.93, 95% CI 0.72 to 1.20; 1321 participants; 6 studies; low-certainty evidence); and an increase in all AEs (rate ratio 1.23, 95% CI 1.03 to 1.47; 1321 participants; 6 studies; low-certainty evidence) compared to the observation group. One RCT reported that there may be no difference in HRQoL between the anti-CD20 mAbs (ofatumumab) maintenance and the observation group (mean difference -1.70, 95% CI -8.59 to 5.19; 480 participants; 1 study; low-certainty evidence). Immunomodulatory drug (IMiD): lenalidomide maintenance versus placebo/observation IMiD maintenance therapy likely results in little to no difference in OS (HR 0.91, 95% CI 0.61 to 1.35; 461 participants; 3 studies; moderate-certainty evidence) and likely results in a large increase in PFS (HR 0.37, 95% CI 0.19 to 0.73; 461 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. Regarding harms, IMiD maintenance therapy may result in an increase in grade 3/4 AEs (rate ratio 1.82, 95% CI 1.38 to 2.38; 400 participants; 2 studies; low-certainty evidence) and may result in a slight increase in TRM (risk ratio 1.22, 95% CI 0.35 to 4.29; 458 participants; 3 studies; low-certainty evidence) compared to placebo/observation. The evidence for the effect on TD compared to placebo is very uncertain (risk ratio 0.71, 95% CI 0.47 to 1.05; 400 participants; 2 studies; very low-certainty evidence). IMiD maintenance therapy probably increases all AEs slightly (rate ratio 1.41, 95% CI 1.28 to 1.54; 458 participants; 3 studies; moderate-certainty evidence) compared to placebo/observation. No studies assessed HRQoL. Anti-CD52 monoclonal antibodies (mAbs): alemtuzumab maintenance versus observation Maintenance with alemtuzumab may have little to no effect on PFS, but the evidence is very uncertain (HR 0.55, 95% CI 0.32 to 0.95; 21 participants; 1 study; very low-certainty evidence). We did not identify any study reporting the outcomes OS, HRQoL, grade 3/4 AEs, TRM, TD, or all AEs. AUTHORS' CONCLUSIONS There is currently moderate- to very low-certainty evidence available regarding the benefits and harms of maintenance therapy in people with CLL. Anti-CD20 mAbs maintenance improved PFS, but also increased grade 3/4 AEs and all AEs. IMiD maintenance had a large effect on PFS, but also increased grade 3/4 AEs. However, none of the above-mentioned maintenance interventions show differences in OS between the maintenance and control groups. The effects of alemtuzumab maintenance are uncertain, coupled with a warning for drug-related infectious toxicity. We found no studies evaluating other novel maintenance interventions, such as B-cell receptor inhibitors, B-cell leukaemia-2/lymphoma-2 inhibitors, or obinutuzumab.
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Affiliation(s)
- Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ying Wu
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chuan Huang
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Fen Zou
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ju-Chun Cheng
- Department of Pharmacy, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Liang Ho
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Criscuolo M, Fracchiolla N, Farina F, Verga L, Pagano L, Busca A. A review of prophylactic regimens to prevent invasive fungal infections in hematology patients undergoing chemotherapy or stem cell transplantation. Expert Rev Hematol 2023; 16:963-980. [PMID: 38044878 DOI: 10.1080/17474086.2023.2290639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION The recent introduction of targeted therapies, including monoclonal antibodies, tyrosine-kinase inhibitors, and immunotherapies has improved the cure rate of hematologic patients. The implication of personalized treatment on primary antifungal prophylaxis will be discussed. AREAS COVERED We reviewed the literature for clinical trials reporting the rate of invasive fungal infections during targeted and cellular therapies and stem cell transplant, and the most recent international guidelines for primary antifungal prophylaxis. EXPERT OPINION As the use of personalized therapies is growing, the risk of invasive fungal infection has emerged in various clinical settings. Therefore, it is possible that the use of mold-active antifungal prophylaxis would spread in the next years and the risk of breakthrough infections would increase. The introduction of new antifungal agents in the clinical armamentarium is expected to reduce clinical unmet needs concerning the management of primary antifungal prophylaxis and improve outcome of patients.
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Affiliation(s)
- Marianna Criscuolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Nicola Fracchiolla
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | | | | | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Alessandro Busca
- Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Department of Oncology, SSCVD Trapianto di Cellule Staminali Torino, Torino, Italy
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Little JS, Weiss ZF, Hammond SP. Invasive Fungal Infections and Targeted Therapies in Hematological Malignancies. J Fungi (Basel) 2021; 7:1058. [PMID: 34947040 PMCID: PMC8706272 DOI: 10.3390/jof7121058] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 01/02/2023] Open
Abstract
The use of targeted biologic therapies for hematological malignancies has greatly expanded in recent years. These agents act upon specific molecular pathways in order to target malignant cells but frequently have broader effects involving both innate and adaptive immunity. Patients with hematological malignancies have unique risk factors for infection, including immune dysregulation related to their underlying disease and sequelae of prior treatment regimens. Determining the individual risk of infection related to any novel agent is challenging in this setting. Invasive fungal infections (IFIs) represent one of the most morbid infectious complications observed in hematological malignancy. In recent years, growing evidence suggests that certain small molecule inhibitors, such as BTK inhibitors and PI3K inhibitors, may cause an increased risk of IFI in certain patients. It is imperative to better understand the impact that novel targeted therapies might have on the development of IFIs in this high-risk patient population.
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Affiliation(s)
- Jessica S. Little
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Zoe F. Weiss
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
| | - Sarah P. Hammond
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA;
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Li R, Liang M, Liang X, Yang L, Su M, Lai KP. Chemotherapeutic Effectiveness of Combining Cetuximab for Metastatic Colorectal Cancer Treatment: A System Review and Meta-Analysis. Front Oncol 2020; 10:868. [PMID: 32547954 PMCID: PMC7270202 DOI: 10.3389/fonc.2020.00868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 05/04/2020] [Indexed: 12/28/2022] Open
Abstract
This meta-analysis used the database including PubMed, Medline, Cochrane Library, CNKI, Chinese-Cqvip, and Wanfang for randomized controlled trials (RCTs) to investigate the clinical effectiveness for combining cetuximab treatment with chemotherapy for treating metastatic colorectal cancer (mCRC). A total of 12 RCTs involved 7,108 patients with mCRC were included. The patients received chemotherapy with (3,521 cases) or without cetuximab (3,587 cases). Outcomes were overall survival (OS), progression-free survival (PFS), disease control rate (DCR), overall response rate (ORR), odd ratio (OR), and risk ratio (HR). Our results showed that the chemotherapy alone group has shorter OS, PFS, and ORR than the chemotherapy plus cetuximab group, with significant differences (PFS:HR = 0.77, 95% CI = 0.72–0.82, P < 0.00001; OS:HR = 0.88, 95% CI = 0.79–0.99, P = 0.03; ORR:OR = 1.79, 95% CI = 1.30–2.47; P = 0.0003). Results of subgroup analysis showed that cetuximab treatment prolonged PFS and OS in KRAS wild-type patients, with statistically significant differences (PFS:HR = 0.79, 95% CI = 0.65–0.95, P = 0.01; OS:HR = 0.85, 95% CI = 0.74–0.98, P = 0.02). Combining cetuximab with chemotherapy, the PFS and OS of wild-type KRAS patients and the ORR of all patients were significantly improved.
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Affiliation(s)
- Rong Li
- Guangxi Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China
| | - Minqing Liang
- Department of Pharmacy, Guigang City People's Hospital, The Eighth Affiliated Hospital of Guangxi Medical University, Guigang, China
| | - Xiao Liang
- Guangxi Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China
| | - Lu Yang
- Guangxi Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China
| | - Min Su
- Guangxi Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China
| | - Keng Po Lai
- Guangxi Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China.,Department of Chemistry, City University of Hong Kong, Hong Kong, China
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Hallek M, Shanafelt TD, Eichhorst B. Chronic lymphocytic leukaemia. Lancet 2018; 391:1524-1537. [PMID: 29477250 DOI: 10.1016/s0140-6736(18)30422-7] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/30/2017] [Accepted: 11/13/2017] [Indexed: 12/15/2022]
Abstract
Important advances in understanding the pathogenesis of chronic lymphocytic leukaemia in the past two decades have led to the development of new prognostic tools and novel targeted therapies that have improved clinical outcome. Chronic lymphocytic leukaemia is the most common type of leukaemia in developed countries, and the median age at diagnosis is 72 years. The criteria for initiating treatment rely on the Rai and Binet staging systems and on the presence of disease-related symptoms. For many patients with chronic lymphocytic leukaemia, treatment with chemotherapy and anti-CD20 monoclonal antibodies is the standard of care. The impressive efficacy of kinase inhibitors ibrutinib and idelalisib and the BCL-2 antagonist venetoclax have changed the standard of care in specific subsets of patients. In this Seminar, we review the recent progress in the management of chronic lymphocytic leukaemia and highlight new questions surrounding the optimal disease management.
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MESH Headings
- Adenine/analogs & derivatives
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Diagnosis, Differential
- Genetic Predisposition to Disease
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Mutation
- Piperidines
- Prognosis
- Purines/therapeutic use
- Pyrazoles/therapeutic use
- Pyrimidines/therapeutic use
- Quinazolinones/therapeutic use
- Recurrence
- Risk Factors
- Sulfonamides/therapeutic use
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Michael Hallek
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany.
| | | | - Barbara Eichhorst
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany
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Soe ZN, Allsup D. The use of ofatumumab in the treatment of B-cell malignancies. Future Oncol 2017; 13:2611-2628. [DOI: 10.2217/fon-2017-0275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Ofatumumab has been extensively studied in the treatment of B-cell malignancies. Currently, it has been approved for the treatment of chronic lymphocytic leukemia in a number of different situations. However, there is still no compelling evidence confirming the superiority of ofatumumab over rituximab in vivo. In this article, we summarize the currently available clinical data supporting the use of ofatumumab in the treatment of B-cell malignancies. The clinical studies were searched from clinicaltrials.gov with the key words ofatumumab, HuMax-CD20. Out of 115 trials available, studies for B-cell malignancies were selected, followed by selection of completed studies with results and active ongoing studies. The results from completed studies were thoroughly analyzed and active ongoing studies were listed in tables.
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Affiliation(s)
- Zar Ni Soe
- Department of Haematology, Hull & East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, England, UK
| | - David Allsup
- Department of Haematology, Hull & East Yorkshire Hospitals NHS Trust, Hull, East Yorkshire, England, UK
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Pers YM, Jorgensen C. Perspectives of ofatumumab as CD20 targeted therapy in rheumatoid arthritis and other autoimmune diseases. Immunotherapy 2017; 8:1091-6. [PMID: 27485081 DOI: 10.2217/imt-2016-0003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune condition viewed as a severe destructive disease. The treatment strategies include anti-CD20 monoclonal antibody (mAb)-targeting B cells. Ofatumumab specifically targets a membrane-proximal epitope on the CD20 molecule distinct from other anti-CD20 antibodies including rituximab and ocrelizumab, and bind the epitope located on the large loop of CD20. This explains a more durable B-cell depletion and a different pharmacodynamic. We review the pharmacodynamic of B-cell depletion and analyze the results in RA and other B-cell-mediated autoimmune diseases. The randomized trial in RA showed clinical efficacy comparable to rituximab at week 24. However, structural impact has not been demonstrated. Studies including RA patients refractory to rituximab would be useful to define the optimal strategy of ofatumumab therapy.
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Affiliation(s)
- Yves Marie Pers
- Inserm, U1183, Hôpital Saint-Eloi, Montpellier, F-34295 France.,Université MONTPELLIER, UFR de Médecine, Montpellier, F-34000 France.,Service d'immuno-Rhumatologie, CHU Lapeyronie, Montpellier, F-34295 France
| | - Christian Jorgensen
- Inserm, U1183, Hôpital Saint-Eloi, Montpellier, F-34295 France.,Université MONTPELLIER, UFR de Médecine, Montpellier, F-34000 France.,Service d'immuno-Rhumatologie, CHU Lapeyronie, Montpellier, F-34295 France
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Wu Y, Wang Y, Gu Y, Xia J, Kong X, Qian Q, Hong Y. Safety and efficacy of Ofatumumab in chronic lymphocytic leukemia: a systematic review and meta-analysis. Hematology 2017; 22:578-584. [PMID: 28580841 DOI: 10.1080/10245332.2017.1333974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Yougen Wu
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yang Wang
- Department of General Psychiatry, Shanghai Mental Health Center, Shanghai Jiaotong University, Shanghai, China
| | - Yuting Gu
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Ju Xia
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Xiaoyang Kong
- Department of Hematology, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Qingqing Qian
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
| | - Yang Hong
- Medical Institution Conducting Clinical Trials for Human Used Drug, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
- Department of Osteology, The Fifth People’s Hospital of Shanghai, Fudan University, Shanghai, China
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Al-Sawaf O, Fischer K, Herling CD, Ritgen M, Böttcher S, Bahlo J, Elter T, Stilgenbauer S, Eichhorst BF, Busch R, Elberskirch U, Abenhardt W, Kneba M, Hallek M, Wendtner CM. Alemtuzumab consolidation in chronic lymphocytic leukaemia: a phase I/II multicentre trial. Eur J Haematol 2016; 98:254-262. [PMID: 27862308 DOI: 10.1111/ejh.12825] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Despite high rates of long-lasting remissions in patients with chronic lymphocytic leukaemia (CLL) treated with chemoimmunotherapy, none of the current therapeutic approaches is curative with the exception of allogeneic transplantation. One strategy to extend progression-free survival and long-term survival might be the establishment of consolidation therapies. METHODS In this trial, patients with complete or partial second remission after fludarabine-based treatment received consolidation therapy with alemtuzumab. The aim of this phase I/II trial was to determine the maximal tolerable dose (MTD) of alemtuzumab consolidation and to evaluate safety and efficacy in patients who responded to second-line fludarabine-based treatment. Thirteen patients in complete (CR) or partial remission (PR) received alemtuzumab dose escalation starting with 10 mg intravenously (iv) once weekly for 8 wk and increasing in 10-mg intervals per dose level. RESULTS The main dose-limiting toxicities (DLTs) were infectious complications, and the MTD was determined at 10 mg. After alemtuzumab consolidation, seven of 13 patients (53%) were in CR, and four of these patients (30.7%) achieved minimal residual disease (MRD) negativity (<1 × 10E-4). At a median follow-up of 71.5 months, four patients were progression-free, with a median progression-free survival (PFS) of 28.5 months after the end of second-line treatment. CONCLUSION The results provide a safe and efficient schedule with weekly intravenous application of 10 mg of alemtuzumab as a consolidation regime in patients with CLL.
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Affiliation(s)
- Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Carmen D Herling
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sebastian Böttcher
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jasmin Bahlo
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Thomas Elter
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | | | - Barbara F Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Raymonde Busch
- Institute for Medical Statistic and Epidemiology, Technical University, Munich, Germany
| | - Ute Elberskirch
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | | | - Michael Kneba
- Department II of Internal Medicine, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany
| | - Clemens-Martin Wendtner
- Department I of Internal Medicine and Center of Integrated Oncology Cologne-Bonn, German CLL Study group, University of Cologne, Cologne, Germany.,Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, Klinikum Schwabing, Munich, Germany
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Flinn IW, Ruppert AS, Harwin W, Waterhouse D, Papish S, Jones JA, Hainsworth J, Byrd JC. A phase II study of two dose levels of ofatumumab induction followed by maintenance therapy in symptomatic, previously untreated chronic lymphocytic leukemia. Am J Hematol 2016; 91:1020-5. [PMID: 27387131 DOI: 10.1002/ajh.24468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
Despite the recent advances in treatment of CLL with targeted agents such as ibrutinib, availability of nonchemotherapy based therapies is desired. Given the 58% response rate (1996 NCI-WG criteria) of single agent ofatumumab in CLL refractory to fludarabine and alemtuzumab, we initiated a phase II trial examining response, safety, and progression-free survival (PFS) of ofatumumab as front-line monotherapy. Patients enrolled included untreated, symptomatic CLL patients over the age of 65 or those who were inappropriate/did not desire chemotherapy. Two cohorts were enrolled sequentially examining either 1 g (33 patients) or 2 g (44 patients) weekly for 8 weeks followed by maintenance dosing every 2 months for a total of 24 months. Patients receiving 1 g were older than those receiving 2 g, but there were no significant differences in other clinical characteristics. The best overall response rates in the 1 and 2 g patient cohorts were 72 and 89% (1996 NCI-WG criteria), respectively (54 and 68%, respectively, using 2008 IWCLL criteria). All but two responses were partial. The 24-month estimated PFS rates were 46 and 78%, respectively. Response and PFS was lower in del(17p) and del(11q) CLL patients. Differences in PFS between dose cohorts were statistically significant and remained so when adjusting for age or high-risk cytogenetics. Toxicity of this treatment was mild with only six patients not completing therapy due to toxicity. Ofatumumab induction followed by maintenance therapy in untreated CLL represents a well-tolerated and active regimen, particularly with the 2 g of ofatumumab. Am. J. Hematol. 91:1020-1025, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ian W. Flinn
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - Amy S. Ruppert
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - William Harwin
- Sarah Cannon Research Institute; Nashville Tennessee
- Florida Cancer Specialists; Ft. Myers Florida
| | - David Waterhouse
- Sarah Cannon Research Institute; Nashville Tennessee
- Oncology Hematology Care; Cincinnati Ohio
| | - Steven Papish
- Hematology-Oncology Associates of Northern NJ; Morristown New Jersey
| | - Jeffrey A. Jones
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - John Hainsworth
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - John C. Byrd
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
- Division of Medicinal Chemistry; College of Pharmacy, The Ohio State University; Columbus Ohio
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11
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Laurenti L, Innocenti I, Autore F, Sica S, Efremov DG. New developments in the management of chronic lymphocytic leukemia: role of ofatumumab. Onco Targets Ther 2016; 9:421-9. [PMID: 26855591 PMCID: PMC4725726 DOI: 10.2147/ott.s72845] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Ofatumumab is one of the three anti-CD20 monoclonal antibodies currently available for the treatment of chronic lymphocytic leukemia (CLL). The US Food and Drug Administration (FDA) approved the use of ofatumumab in patients with CLL refractory to fludarabine and alemtuzumab in 2009, and the European Medicines Agency (EMA) granted approval for the same indication in 2010. Subsequent positive results of ofatumumab in combination with chlorambucil in treatment-naïve patients led the FDA in April 2014 to approve the use of this combination for first-line treatment of patients with CLL for whom fludarabine-based therapy is considered inappropriate. Later that year, the EMA approved the use of ofatumumab in combination with chlorambucil or bendamustine for the same indication. Ofatumumab has also shown potential as maintenance therapy for patients with relapsed CLL; an application to broaden the label for ofatumumab as maintenance therapy was submitted earlier this year to the EMA and FDA. Finally, ofatumumab has shown promising activity in combination with ibrutinib or idelalisib in relapsed/refractory CLL patients; combinations of ofatumumab with B-cell-receptor pathway inhibitors could represent another potential use of this antibody in the near future.
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Affiliation(s)
- Luca Laurenti
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Idanna Innocenti
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Autore
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Simona Sica
- Department of Hematology, Catholic University of the Sacred Heart, Rome, Italy
| | - Dimitar G Efremov
- Molecular Hematology, International Centre for Genetic Engineering and Biotechnology, Monterotondo, Italy
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12
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Dahlberg CIM, Sarhan D, Chrobok M, Duru AD, Alici E. Natural Killer Cell-Based Therapies Targeting Cancer: Possible Strategies to Gain and Sustain Anti-Tumor Activity. Front Immunol 2015; 6:605. [PMID: 26648934 PMCID: PMC4663254 DOI: 10.3389/fimmu.2015.00605] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 11/13/2015] [Indexed: 12/14/2022] Open
Abstract
Natural killer (NK) cells were discovered 40 years ago, by their ability to recognize and kill tumor cells without the requirement of prior antigen exposure. Since then, NK cells have been seen as promising agents for cell-based cancer therapies. However, NK cells represent only a minor fraction of the human lymphocyte population. Their skewed phenotype and impaired functionality during cancer progression necessitates the development of clinical protocols to activate and expand to high numbers ex vivo to be able to infuse sufficient numbers of functional NK cells to the cancer patients. Initial NK cell-based clinical trials suggested that NK cell-infusion is safe and feasible with almost no NK cell-related toxicity, including graft-versus-host disease. Complete remission and increased disease-free survival is shown in a small number of patients with hematological malignances. Furthermore, successful adoptive NK cell-based therapies from haploidentical donors have been demonstrated. Disappointingly, only limited anti-tumor effects have been demonstrated following NK cell infusion in patients with solid tumors. While NK cells have great potential in targeting tumor cells, the efficiency of NK cell functions in the tumor microenvironment is yet unclear. The failure of immune surveillance may in part be due to sustained immunological pressure on tumor cells resulting in the development of tumor escape variants that are invisible to the immune system. Alternatively, this could be due to the complex network of immune-suppressive compartments in the tumor microenvironment, including myeloid-derived suppressor cells, tumor-associated macrophages, and regulatory T cells. Although the negative effect of the tumor microenvironment on NK cells can be transiently reverted by ex vivo expansion and long-term activation, the aforementioned NK cell/tumor microenvironment interactions upon reinfusion are not fully elucidated. Within this context, genetic modification of NK cells may provide new possibilities for developing effective cancer immunotherapies by improving NK cell responses and making them less susceptible to the tumor microenvironment. Within this review, we will discuss clinical trials using NK cells with a specific reflection on novel potential strategies, such as genetic modification of NK cells and complementary therapies aimed at improving the clinical outcome of NK cell-based immune therapies.
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Affiliation(s)
- Carin I M Dahlberg
- Cell Therapies Institute, Nova Southeastern University , Fort Lauderdale, FL , USA ; Cell and Gene Therapy Group, Center for Hematology and Regenerative Medicine (HERM), Karolinska University Hospital Huddinge, NOVUM , Stockholm , Sweden
| | - Dhifaf Sarhan
- Oncology-Pathology, Cancer Center Karolinska, Karolinska Institutet , Stockholm , Sweden ; Division of Hematology, Oncology and Transplantation, Masonic Cancer Research Center, University of Minnesota , Minnesota, MN , USA
| | - Michael Chrobok
- Cell Therapies Institute, Nova Southeastern University , Fort Lauderdale, FL , USA ; Cell and Gene Therapy Group, Center for Hematology and Regenerative Medicine (HERM), Karolinska University Hospital Huddinge, NOVUM , Stockholm , Sweden
| | - Adil D Duru
- Cell Therapies Institute, Nova Southeastern University , Fort Lauderdale, FL , USA ; Cell and Gene Therapy Group, Center for Hematology and Regenerative Medicine (HERM), Karolinska University Hospital Huddinge, NOVUM , Stockholm , Sweden
| | - Evren Alici
- Cell Therapies Institute, Nova Southeastern University , Fort Lauderdale, FL , USA ; Cell and Gene Therapy Group, Center for Hematology and Regenerative Medicine (HERM), Karolinska University Hospital Huddinge, NOVUM , Stockholm , Sweden ; Hematology Center, Karolinska University Hospital Huddinge , Stockholm , Sweden
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13
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Frustaci AM, Tedeschi A, Picardi P, Cairoli R, Montillo M. Clinical utility and patient considerations in the use of ofatumumab in chronic lymphocytic leukemia. Biologics 2015; 9:75-86. [PMID: 26425075 PMCID: PMC4583123 DOI: 10.2147/btt.s60503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Treatment aim for chronic lymphocytic leukemia has been radically changed over the past years from providing only a palliative approach to reaching disease eradication and improving survival. Ofatumumab is a monoclonal humanized antibody with peculiar in vitro and in vivo properties, at present approved for double fludarabine and alemtuzumab refractory chronic lymphocytic leukemia. Its efficacy in this subset of patients, who typically have an unfavorable prognosis, facilitated its use in different Phase II and III trials. Ofatumumab as single agent or combined with chemotherapeutic or biologic agents, led to sundry results in the setting of both previously treated or untreated patients. Its role in maintenance therapy is also under investigation. Further advances concerning ofatumumab administration as first line therapy in combination with chlorambucil, came recently from the COMPLEMENT 1 study. Results from this trial will open the door to new perspectives of its use in treatment-naïve patients. Ofatumumab was well tolerated in almost all the studies, with the main adverse events relating mostly to infusion reaction. Hematologic toxicity, especially neutropenia, was also common. A significant improvement in patients' quality of life was reported following ofatumumab treatment and this was mainly due to its effect on constitutional symptoms. Nevertheless, some concerns remain regarding the long-term efficacy of the drug in terms of response duration and survival. The real strength of this drug needs to be confirmed by further studies and direct comparative trials.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Ca’ Granda Hospital, Milan, Italy
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