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Goergen E, Al-Sawaf O. The prognostic significance of genomic complexity in patients with CLL. Leuk Lymphoma 2024:1-9. [PMID: 38593054 DOI: 10.1080/10428194.2024.2333448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
Chromosomal aberrations are a common feature of cancer and can fuel cancer progression and treatment resistance. In chronic lymphocytic leukemia (CLL), the presence of multiple chromosomal aberrations is commonly referred to as "genomic complexity" or "complex karyotype"- (CKT). In the context of chemo- and chemoimmunotherapy, genomic complexity is associated with poor response to treatment and short survival, while some targeted therapies are able to mitigate its adverse prognostic impact. This article reviews currently available data and literature on the role of genomic complexity in CLL. The currently established tools to measure genomic complexity in patients with CLL are summarized and their strengths and weaknesses for routine diagnostics are evaluated. Moreover, possible definitions of CKT as an indicator for genomic complexity are discussed. Finally, data on the impact of CKT on clinical outcomes of patients with CLL are reviewed and the implications for patient stratification are presented.
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Affiliation(s)
- Ellinor Goergen
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
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2
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Eichhorst B, Hacken ET. Special issue on chronic lymphocytic leukemia: Prognostication and therapeutic options introductory editorial. Semin Hematol 2024; 61:69-72. [PMID: 38599948 DOI: 10.1053/j.seminhematol.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Barbara Eichhorst
- Department for Internal Medicine and Center für Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, University of Cologne, Cologne, Germany.
| | - Elisa Ten Hacken
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY.
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3
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Coombs CC. Frontline Therapy of CLL-Changing Treatment Paradigms. Curr Hematol Malig Rep 2024; 19:65-74. [PMID: 38337108 DOI: 10.1007/s11899-024-00726-x] [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] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW The therapeutic landscape for chronic lymphocytic leukemia (CLL) has undergone a complete makeover following the introduction of highly effective targeted therapies, beginning with ibrutinib which first attained regulatory approval for CLL in 2014. RECENT FINDINGS In recent years, we have seen further refinement of therapeutic options with the development of newer-generation Bruton's tyrosine kinase inhibitors (BTKi) including acalabrutinib and zanubrutinib that improve upon the safety of ibrutinib. Additionally, venetoclax-based approaches, combined with anti-CD20 antibodies, have allowed for time-limited targeted therapeutic strategies which are particularly attractive for certain subsets of patients though have demonstrated efficacy across all subgroups. Lastly, there is an ongoing movement toward the development of time-limited strategies inclusive of both a BTKi and venetoclax that may further widen potential options. CLL patients requiring frontline therapy have a unique burden of choice between highly effective therapies that differ substantially with respect to side effect profiles and schedules. This review will focus on the frontline management of CLL in the setting of these rapidly changing options.
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Affiliation(s)
- Catherine C Coombs
- University of California Irvine, 200 S. Manchester Avenue, Suite 400, Room 428, ZOT 4061, Orange, Irvine, CA, 92868, USA.
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Moia R, Gaidano G. Prognostication in chronic lymphocytic leukemia. Semin Hematol 2024; 61:83-90. [PMID: 38523019 DOI: 10.1053/j.seminhematol.2024.02.002] [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: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. CLL is a highly heterogeneous disease: some patients may never require therapy and others relapse several times after different therapeutic strategies. Therefore, in CLL, prognostic markers are essential to capture high-risk patients for different clinical endpoints including early treatment requirement, early progression after BTK or BCL2 inhibitors and Richter transformation. In early stage CLL, different biological and clinical biomarkers have been identified to predict time to treatment requirement that could be used to identify the most appropriate population for early intervention clinical trial. However, at the moment, the standard of care for early stage CLL remains watch & wait since no survival benefit has been identified in clinical trials with chemoimmunotherapy and with BTK inhibitors. In patients requiring treatment TP53 disruptions identify high-risk patients who benefit the most from long-term continuous therapy with BTKi. On the opposite side of the spectrum, IGHV mutated patients devoid of TP53 disruption benefit the most from fixed-duration therapy with venetoclax-obinutuzumab. In between, the highly heterogenous subgroup of patients with IGHV unmutated genes represents the group in which further efforts are needed to identify additional prognostic biomarkers aimed at selecting patients who can benefit from fixed-duration and patients who can benefit from long term BTKi therapy. In the context of the aggressive transformation of CLL, namely Richter syndrome, the clonal relationship to the CLL counterpart represents the strongest prognostic biomarker. Clonally related Richter syndrome still represents an unmet clinical need which requires further efforts to identify new therapeutic strategies.
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MESH Headings
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Humans
- Prognosis
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Mutation
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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Visentin A, Frazzetto S, Trentin L, Chiarenza A. Innovative Combinations, Cellular Therapies and Bispecific Antibodies for Chronic Lymphocytic Leukemia: A Narrative Review. Cancers (Basel) 2024; 16:1290. [PMID: 38610967 PMCID: PMC11011076 DOI: 10.3390/cancers16071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
In the last few years, several agents targeting molecules that sustain the survival and the proliferation of chronic lymphocytic leukemia (CLL) cells have become clinically available. Most of these drugs target surface proteins, such as CD19 or CD20, via monoclonal or bispecific monoclonal antibodies (BsAbs), CAR T cells, intracellular proteins like BTK by using covalent or non-covalent inhibitors or BCL2 with first or second generation BH3-mimetics. Since the management of CLL is evolving quickly, in this review we highlighted the most important innovative treatments including novel double and triple combination therapies, CAR T cells and BsAbs for CLL. Recently, a large number of studies on novel combinations and newer strategic options for CLL therapy have been published or presented at international conferences, which were summarized and linked together. Although the management of treatment with a single continuous agent is easier, the emergence of protein mutations, long-term toxicities and costs are important concerns that favor the use of a fixed duration therapy. In the future, a measurable residual disease (MRD)-guided treatment cessation and MRD-based re-initiation of targeted therapy seems to be a more feasible approach, allowing identification of the patients who might benefit from continuous therapy or who might need a consolidation with BsAbs or CAR T cells to clear the neoplastic clone.
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Affiliation(s)
- Andrea Visentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Sara Frazzetto
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
| | - Livio Trentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Annalisa Chiarenza
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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Rhodes JM. MRD-directed therapy in CLL: ready for prime time? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:413-420. [PMID: 38066928 PMCID: PMC10727082 DOI: 10.1182/hematology.2023000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
In recent years, the treatment paradigm for patients with chronic lymphocytic leukemia (CLL) has moved away from chemoimmunotherapy (CIT) toward the use of novel targeted agents. Commercially available drugs, including Bruton's tyrosine kinase inhibitors and the BCL2 inhibitor venetoclax, often used in combination with anti-CD20 monoclonal antibodies, are now the mainstay of therapy both in the frontline and in relapsed settings. As the landscape for CLL management evolves, therapeutic endpoints need to be redefined. Detection of measurable residual disease (MRD) is a sensitive tool to identify disease burden following treatment with several therapeutic regimens in CLL (including CIT, venetoclax-based regimens, and cellular therapies), and it has demonstrated prognostic value. Despite recent advances, the utility of MRD-directed therapy and attempts to eradicate it in routine clinical practice remain debated. There is little comparative data from clinical trials on the best assay to determine undetectable MRD (U-MRD) and whether its monitoring can lead to changes in treatment strategies. Our review discusses the definitions of MRD, assays for its detection, and its impact on long-term survival outcomes for patients with a CLL diagnosis.
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Affiliation(s)
- Joanna M. Rhodes
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Easaw S, Ezzati S, Coombs CC. SOHO State of the Art Updates and Next Questions: Updates on BTK Inhibitors for the Treatment of Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:697-704. [PMID: 37544810 DOI: 10.1016/j.clml.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
Over the last decade, targeted inhibition of Bruton's tyrosine kinase (BTK) has led to a paradigm shift in the way chronic lymphocytic leukemia (CLL) is managed. BTK inhibitors (BTKi) are broadly classified as covalent BTKI and noncovalent BTKi (cBTKi and ncBTK) Ibrutinib, as the first approved cBTKi, vastly improved outcomes for patients with CLL over prior chemoimmunotherapy regimens. However, long-term use is limited by both intolerance and resistance. The second generation of more selective BTKi were developed to improve tolerability. While these agents have led to an improved safety profile in comparison to Ibrutinib (both acalabrutinib and zanubrutinib), and improved efficacy (zanubrutinib), intolerance occasionally occurs, and resistance remains a challenge. The third generation of BTKi, which noncovalently or reversibly inhibits BTK, has shown promising results in early phase trials and are being evaluated in the phase 3 setting. These drugs could be an effective treatment option in patients with either resistance and intolerance to cBTKi. The most recent development in therapeutic agents targeting BTK is the development of BTK degraders. By removing BTK, as opposed to inhibiting it, these drugs could remain efficacious irrespective of BTK resistance mutations, however clinical data are limited at this time. This review summarizes the evolution and ongoing development of newer BTKi and BTK degraders in the management of CLL, with a focus of future directions in this field, including how emerging clinical data could inform therapeutic sequencing in CLL management.
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Affiliation(s)
| | - Shawyon Ezzati
- California Northstate University College of Medicine, Elk Grove, CA
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Rogers KA. A CAPTIVATEing Analysis for Higher-Risk CLL. Clin Cancer Res 2023; 29:2561-2562. [PMID: 37289004 PMCID: PMC10443675 DOI: 10.1158/1078-0432.ccr-23-0807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/17/2023] [Accepted: 05/05/2023] [Indexed: 06/09/2023]
Abstract
In an exploratory analysis of the phase II CAPTIVATE study, previously untreated patients with chronic lymphocytic leukemia with a higher-risk feature of immune globulin heavy chain variable (IGHV) unmutated status, del(17p), and/or TP53 mutation had similar efficacy and safety outcomes compared with patients without a higher-risk feature when treated with fixed-duration ibrutinib and venetoclax. See related article by Allan et al., p. 2593.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Piperidines
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Mutation
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