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Rios-Olais FA, McGary AK, Tsang M, Almader-Douglas D, Leis JF, Buras MR, Hilal T. Measurable Residual Disease and Clinical Outcomes in Chronic Lymphocytic Leukemia: A Systematic Review and Meta-Analysis. JAMA Oncol 2024:2821029. [PMID: 38990562 PMCID: PMC11240229 DOI: 10.1001/jamaoncol.2024.2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 07/12/2024]
Abstract
Importance Measurable residual disease (MRD) refers to the presence of disease at low levels not detected by conventional pathologic analysis. The association of MRD status as a surrogate end point of clinical outcome in chronic lymphocytic leukemia (CLL) has not been established in the era of targeted agents. Assessing the association of MRD with progression-free survival (PFS) may improve its role as a surrogate marker and allow its use to accelerate drug development. Objective To assess the association between MRD and PFS in CLL using data from prospective clinical trials that studied targeted agents or obinutuzumab-based treatment. Data Sources Clinical studies on CLL were identified via searches of PubMed, Embase, Scopus, and Web of Science from inception through July 31, 2023. Study Selection Prospective, single-arm, and randomized clinical trials that assessed targeted agents or obinutuzumab-based treatment and reported PFS by MRD status were included. Studies with insufficient description of MRD information were excluded. Data Extraction and Synthesis Study sample size, median patient age, median follow-up time, line of treatment, MRD detection method and time points, and survival outcomes were extracted. Main Outcomes and Measures Analyses of survival probabilities and hazard ratios (HRs) were conducted for PFS according to MRD status. Meta-analyses were performed using a random-effects model. Results A total of 11 prospective clinical trials (9 randomized and 2 nonrandomized) including 2765 patients were analyzed. Achieving undetectable MRD (uMRD) at 0.01% was associated with an HR of 0.28 (95% CI, 0.20-0.39; P < .001) for PFS. Median PFS was not reached in both groups (uMRD vs MRD), but the estimated 24-month PFS was better in the uMRD group (91.9% [95% CI, 88.8%-95.2%] vs 75.3% [95% CI, 64.7%-87.6%]; P < .001). The association of uMRD with PFS was observed in subgroup analyses in the first-line treatment setting (HR, 0.24; 95% CI, 0.18-0.33), relapsed or refractory disease setting (HR, 0.34; 95% CI, 0.16-0.71), and trials using time-limited therapy (HR, 0.28; 95% CI, 0.19-0.40). Conclusions and Relevance The findings of this systematic review and meta-analysis suggest that assessing MRD status as an end point in clinical trials and as a surrogate of PFS may improve trial efficiency and potentially allow for accelerated drug registration.
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Affiliation(s)
- Fausto Alfredo Rios-Olais
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alyssa K. McGary
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, Arizona
| | - Mazie Tsang
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Jose F. Leis
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | - Matthew R. Buras
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Talal Hilal
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
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Bommier C, Maurer MJ, Lambert J. What clinicians should know about surrogate end points in hematologic malignancies. Blood 2024; 144:11-20. [PMID: 38603637 DOI: 10.1182/blood.2023022269] [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: 10/10/2023] [Revised: 03/14/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
ABSTRACT Use of surrogates as primary end points is commonplace in hematology/oncology clinical trials. As opposed to prognostic markers, surrogates are end points that can be measured early and yet can still capture the full effect of treatment, because it would be captured by the true outcome (eg, overall survival). We discuss the level of evidence of the most commonly used end points in hematology and share recommendations on how to apply and evaluate surrogate end points in research and clinical practice. Based on the statistical literature, this clinician-friendly review intends to build a bridge between clinicians and surrogacy specialists.
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Affiliation(s)
- Côme Bommier
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
| | - Matthew John Maurer
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Jerome Lambert
- Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments Team, INSERM, U1153, Assistance Publique-Hôpitaux de Paris Hôpital St Louis, Université Paris Cité, Paris, France
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Chen X, Chen X, Zhao S, Shi Y, Zhang N, Guo Z, Qiao C, Jin H, Zhu L, Zhu H, Li J, Wu Y. Performance of a novel eight-color flow cytometry panel for measurable residual disease assessment of chronic lymphocytic leukemia. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2024; 106:181-191. [PMID: 38535092 DOI: 10.1002/cyto.b.22170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Measurable residual disease (MRD) is an important prognostic indicator of chronic lymphocytic leukemia (CLL). Different flow cytometric panels have been developed for the MRD assessment of CLL in Western countries; however, the application of these panels in China remains largely unexplored. METHODS Owing to the requirements for high accuracy, reproducibility, and comparability of MRD assessment in China, we investigated the performance of a flow cytometric approach (CD45-ROR1 panel) to assess MRD in patients with CLL. The European Research Initiative on CLL (ERIC) eight-color panel was used as the "gold standard." RESULTS The sensitivity, specificity, and concordance rate of the CD45-ROR1 panel in the MRD assessment of CLL were 100% (87/87), 88.5% (23/26), and 97.3% (110/113), respectively. Two of the three inconsistent samples were further verified using next-generation sequencing. In addition, the MRD results obtained from the CD45-ROR1 panel were positively associated with the ERIC eight-color panel results for MRD assessment (R = 0.98, p < 0.0001). MRD detection at low levels (≤1.0%) demonstrated a smaller difference between the two methods (bias, -0.11; 95% CI, -0.90 to 0.68) than that at high levels (>1%). In the reproducibility assessment, the bias was smaller at three data points (within 24, 48, and 72 h) in the CD45-ROR1 panel than in the ERIC eight-color panel. Moreover, MRD levels detected using the CD45-ROR1 panel for the same samples from different laboratories showed a strong statistical correlation (R = 0.99, p < 0.0001) with trivial interlaboratory variation (bias, 0.135; 95% CI, -0.439 to 0.709). In addition, the positivity rate of MRD in the bone marrow samples was higher than that in the peripheral blood samples. CONCLUSIONS Collectively, this study demonstrated that the CD45-ROR1 panel is a reliable method for MRD assessment of CLL with high sensitivity, reproducibility, and reliability.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Flow Cytometry/methods
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/pathology
- Middle Aged
- Leukocyte Common Antigens/analysis
- Male
- Female
- Aged
- Reproducibility of Results
- Immunophenotyping/methods
- Adult
- Sensitivity and Specificity
- Aged, 80 and over
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Affiliation(s)
- Xiao Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Xia Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Sishu Zhao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yu Shi
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Ninghan Zhang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Zhen Guo
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Chun Qiao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Huimin Jin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Liying Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Huayuan Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yujie Wu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
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Pott C, Jurinovic V, Trotman J, Kehden B, Unterhalt M, Herold M, Jagt RVD, Janssens A, Kneba M, Mayer J, Young M, Schmidt C, Knapp A, Nielsen T, Brown H, Spielewoy N, Harbron C, Bottos A, Mundt K, Marcus R, Hiddemann W, Hoster E. Minimal Residual Disease Status Predicts Outcome in Patients With Previously Untreated Follicular Lymphoma: A Prospective Analysis of the Phase III GALLIUM Study. J Clin Oncol 2024; 42:550-561. [PMID: 38096461 DOI: 10.1200/jco.23.00838] [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: 04/17/2023] [Revised: 08/23/2023] [Accepted: 10/12/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE We report an analysis of minimal residual/detectable disease (MRD) as a predictor of outcome in previously untreated patients with follicular lymphoma (FL) from the randomized, multicenter GALLIUM (ClinicalTrials.gov identifier: NCT01332968) trial. PATIENTS AND METHODS Patients received induction with obinutuzumab (G) or rituximab (R) plus bendamustine, or cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or cyclophosphamide, vincristine, prednisone (CVP) chemotherapy, followed by maintenance with the same antibody in responders. MRD status was assessed at predefined time points (mid-induction [MI], end of induction [EOI], and at 4-6 monthly intervals during maintenance and follow-up). Patients with evaluable biomarker data at diagnosis were included in the survival analysis. RESULTS MRD positivity was associated with inferior progression-free survival (PFS) at MI (hazard ratio [HR], 3.03 [95% CI, 2.07 to 4.45]; P < .0001) and EOI (HR, 2.25 [95% CI, 1.53 to 3.32]; P < .0001). MRD response was higher after G- versus R-chemotherapy at MI (94.2% v 88.9%; P = .013) and at EOI (93.1% v 86.7%; P = .0077). Late responders (MI-positive/EOI-negative) had a significantly poorer PFS than early responders (MI-negative/EOI-negative; HR, 3.11 [95% CI, 1.75 to 5.52]; P = .00011). The smallest proportion of MRD positivity was observed in patients receiving bendamustine at MI (4.8% v 16.0% in those receiving CHOP; P < .0001). G appeared to compensate for less effective chemotherapy regimens, with similar MRD response rates observed across the G-chemo groups. During the maintenance period, more patients treated with R than with G were MRD-positive (R-CHOP, 20.7% v G-CHOP, 7.0%; R-CVP, 21.7% v G-CVP, 9.4%). Throughout maintenance, MRD positivity was associated with clinical relapse. CONCLUSION MRD status can determine outcome after induction and during maintenance, and MRD negativity is a prerequisite for long-term disease control in FL. The higher MRD responses after G- versus R-based treatment confirm more effective tumor cell clearance.
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Affiliation(s)
| | - Vindi Jurinovic
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Judith Trotman
- Concord Repatriation General Hospital, University of Sydney, Sydney, NSW, Australia
| | - Britta Kehden
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Unterhalt
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | | | | | | | - Michael Kneba
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jiri Mayer
- University Hospital and Masaryk University, Brno, Czech Republic
| | - Moya Young
- East Kent Hospital, Canterbury, United Kingdom
| | - Christian Schmidt
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | | | | | - Helen Brown
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | | | - Chris Harbron
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | | | | | | | - Wolfgang Hiddemann
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Eva Hoster
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
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5
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Madu AJ, Okoye HC, Muoghalu EA, Ugwu AO, Duru AN, Nonyelu CE, Anigbogu IO, Ezekekwu CA. Impact of Binet Staging versus Tumour Bulk on Treatment Outcome in Chronic Lymphocytic Leukaemia. Niger Postgrad Med J 2024; 31:76-80. [PMID: 38321800 DOI: 10.4103/npmj.npmj_246_23] [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: 10/16/2023] [Accepted: 01/10/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Most of the predictive tools put up to prognosticate treatment outcomes in patients with chronic lymphocytic leukaemia (CLL) are not easily available and affordable in our resource-constrained environment. AIM The aim of this study was to evaluate the impact of staging and some tumour bulk on treatment outcomes of persons with CLL, Enugu, Nigeria. PATIENTS AND METHODS This is a 10-year review of the CLL data from the haemato-oncology unit of a Nigerian tertiary hospital to evaluate the impact of staging and tumour bulk indicators. Data were retrieved from the case notes of 102 patients with CLL receiving care at the facility. Data of interest include basic demographic variables, clinical features including spleen size and disease staging and blood counts. Statistical analysis was done using SPSS version 22. RESULTS The median absolute lymphocyte count (ALC) was 108.05 (confidence interval [CI] = 50.8-201.3, interquartile range [IQR] = 124.4) ×109/L, and duration of survival for the study cohort was 5.5 (CI = 3.5-31.9, IQR = 27) months. Majority (69, 79.3%) were in Stage C. The Binet stage showed a significant association with the ALC (r = 0.338; P = 0.002) but not with spleen size (r = 0.198; P = 0.056). The duration of survival only showed a significant inverse relationship with the ALC (r = 0.35, P = 0.006) but with neither the Binet stage (r = 0.103, P = 0.431) nor spleen size (r = 0.184, P = 0.116). CONCLUSION In CLL patients, ALC at presentation correlates with the duration of survival. We recommend that the ALC at presentation be used as a prognostic marker in our clime.
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Affiliation(s)
- Anazoeze Jude Madu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Helen Chioma Okoye
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Ebele Adaobi Muoghalu
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Angela Ogechukwu Ugwu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Augustine Nwakuche Duru
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Charles Emeka Nonyelu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Ikechukwu Okwudili Anigbogu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
- Department of Haematology and Immunology, University of Nigeria, Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Chinedu Anthony Ezekekwu
- Department of Haematology and Immunology, College of Medicine, University of Nigeria, Ituku-Ozalla Campus, Enugu, Nigeria
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Alshemmari SH, Siddiqui MA, Pandita R, Osman HY, Cherif H, O'Brien S, Marashi M, Al Farsi K. Evidence-Based Management of Chronic Lymphocytic Leukemia: Consensus Statements from the Gulf Region. Acta Haematol 2023; 147:260-279. [PMID: 37751733 DOI: 10.1159/000531675] [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: 09/13/2022] [Accepted: 06/16/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Despite recent advances in diagnosis, prognostication, and treatment options, chronic lymphocytic leukemia (CLL) is still a largely incurable disease. New concepts on diagnosis, staging, treatment, and follow-up on CLL have been incorporated throughout recent years. The lack of regional consensus guidelines has led to varying practices in the management of patients with CLL in the region. This manuscript aims to reach a consensus among expert hematologists regarding the definitions, classifications, and related practices of CLL. The experts developed a set of statements utilizing their personal experience together with the current literature on CLL management. This consensus aims to provide guidance for healthcare professionals involved in the management of CLL and serves as a step in developing regional guidelines. METHODS Eight experts responded to 50 statements regarding the diagnosis, staging, treatment, and prognosis of CLL with three potential answering alternatives ranging between agree, disagree, and abstain. This consensus adopted a modified Delphi consensus methodology. A consensus was reached when at least 75% of the agreement to the answer was reached. This manuscript presents the scientific insights of the participating attendees, panel discussions, and the supporting literature review. RESULTS Of the 50 statements, a consensus was reached on almost all statements. Statements covered CLL-related topics, including diagnostic evaluation, staging, risk assessment, different patient profiles, prognostic evaluation, treatment decisions, therapy sequences, response evaluation, complications, and CLL during the COVID-19 pandemic. CONCLUSION In recent years, CLL management has progressed significantly, with many diagnostic tests and several novel treatments becoming available. This consensus gathers decades of consolidated principles, novel research, and promising prospects for the management of this disease.
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Affiliation(s)
- Salem H Alshemmari
- Department of Medicine, Faculty of Medicine and Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Mustaqeem A Siddiqui
- Hematology and Oncology Division, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- Mayo Clinic Division of Hematology, Rochester, Minnesota, USA
| | - Ramesh Pandita
- Department of Hematology, Kuwait Cancer Control Centre, Shuwaikh, Kuwait
| | - Hani Y Osman
- Oncology Department, Tawam Hospital, Al Ain, United Arab Emirates
| | - Honar Cherif
- Departmant of Hematology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Irvine, California, USA
| | - Mahmoud Marashi
- Department of Hematology, Dubai Healthcare Authority, Dubai, United Arab Emirates
| | - Khalil Al Farsi
- Department of Hematology, Sultan Qaboos University Hospital Muscat, Seeb, Oman
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7
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Yang S, Li N, Zhu R, Feng Y, Zhuo J, Gale RP, Huang X. Impacts of early therapy response, interval to therapy interruption, and cumulative therapy interruption duration on outcome of ibrutinib therapy in relapsed/refractory chronic lymphocytic leukemia. Ann Hematol 2023:10.1007/s00277-023-05309-z. [PMID: 37393401 DOI: 10.1007/s00277-023-05309-z] [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: 11/01/2022] [Accepted: 05/31/2023] [Indexed: 07/03/2023]
Abstract
To investigate the impact of early response and treatment interruption on the survival of patients with relapsed/refractory chronic lymphocytic leukemia or small lymphocytic lymphoma (r/r CLL/SLL) treated with ibrutinib. This post hoc analysis used data of patients received ibrutinib treatment from an open-label, multicenter phase 3 study comparing ibrutinib with rituximab in patients with r/r CLL/SLL. The association of complete or partial response at 6 months, interruption within the first 6 months, cumulative interruption durations during the ibrutinib-treated period with progression-free survival (PFS) and overall survival (OS) were evaluated using the adjusted Cox hazard proportional model. The study included 87 patients treated with ibrutinib, of which 74 patients had at least 6 months of ibrutinib treatment and were analyzed. The response at 6 months did not affect PFS (HR = 0.58, 95%CI: 0.22-1.49) or OS (HR = 0.86, 95%CI: 0.22-3.31). The onset of interruption before or after 6 months was not associated with PFS (HR = 0.88, 95%CI: 0.34-2.30) or OS (HR = 0.75, 95%CI: 0.23-2.52). However, a cumulative interruption of more than 35 days was independently associated with worse PFS (HR = 2.4, 95%CI: 0.99-5.74) and OS (HR = 2.6, 95%CI: 0.88-7.44). Continuous interruption for more than 14 days was associated with a numerically lower 3-year PFS rate (> 14 vs. ≤ 14 days: 42% vs. 73%) and 3-year OS rate (> 14 vs. ≤ 14 days: 58% vs. 84%, both P > 0.05). Response status at 6 months or early therapy interruptions did not affect survival in patients with r/r CLL/SLL treated with ibrutinib. However, a cumulative temporary interruption of more than 35 days could potentially impact patient outcomes.
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Affiliation(s)
- Shenmiao Yang
- Peking University People's Hospital, Peking University Institute of Hematology, 11 Xizhimen Nan Street, Beijing, 100044, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Rong Zhu
- Xian Janssen Pharmaceutical, Beijing & Shanghai, China
| | - Yu Feng
- Xian Janssen Pharmaceutical, Beijing & Shanghai, China
| | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, 11 Xizhimen Nan Street, Beijing, 100044, China.
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9
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Rios-Olais FA, Hilal T. Measurable Residual Disease in Chronic Lymphocytic Leukemia: Current Understanding and Evolving Role in Clinical Practice. Curr Treat Options Oncol 2023:10.1007/s11864-023-01103-1. [PMID: 37195588 DOI: 10.1007/s11864-023-01103-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
OPINION STATEMENT Treatment of chronic lymphocytic leukemia (CLL) has evolved dramatically during the last decade, from chemoimmunotherapy (CIT)-based therapies to newer B-cell receptor (BCR) signaling targeting agents, which are sometimes given as continuous schemes. Response to treatment was traditionally defined according to clinical variables designed to assign a response category. Interest in assessing for deeper responses in CLL by the means of measurable residual disease (MRD) testing has been the subject of research during the last several years. Analyses and sub-analyses of clinical trials have shown that achieving undetectable MRD (uMRD) in CLL is an important prognostic factor. In this review, we summarize the available evidence about MRD in CLL, from the various assays available for measurement, the compartment to test, the impact of reaching uMRD according to the treatment regimen, and the results of fixed duration treatment guided by MRD trials. Finally, we summarize how MRD can be incorporated in clinical practice and how it may guide fixed duration treatment in the future should evidence continue to accumulate in that direction.
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Affiliation(s)
| | - Talal Hilal
- Mayo Clinic, 5777 E. Mayo Boulevard, Phoenix, AZ, 85054, USA.
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10
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Fisher A, Goradia H, Martinez-Calle N, Patten PEM, Munir T. The evolving use of measurable residual disease in chronic lymphocytic leukemia clinical trials. Front Oncol 2023; 13:1130617. [PMID: 36910619 PMCID: PMC9992794 DOI: 10.3389/fonc.2023.1130617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023] Open
Abstract
Measurable residual disease (MRD) status in chronic lymphocytic leukemia (CLL), assessed on and after treatment, correlates with increased progression-free and overall survival benefit. More recently, MRD assessment has been included in large clinical trials as a primary outcome and is increasingly used in routine practice as a prognostic tool, a therapeutic goal, and potentially a trigger for early intervention. Modern therapy for CLL delivers prolonged remissions, causing readout of traditional trial outcomes such as progression-free and overall survival to be inherently delayed. This represents a barrier for the rapid incorporation of novel drugs to the overall therapeutic armamentarium. MRD offers a dynamic and robust platform for the assessment of treatment efficacy in CLL, complementing traditional outcome measures and accelerating access to novel drugs. Here, we provide a comprehensive review of recent major clinical trials of CLL therapy, focusing on small-molecule inhibitors and monoclonal antibody combinations that have recently emerged as the standard frontline and relapse treatment options. We explore the assessment and reporting of MRD (including novel techniques) and the challenges of standardization and provide a comprehensive review of the relevance and adequacy of MRD as a clinical trial endpoint. We further discuss the impact that MRD data have on clinical decision-making and how it can influence a patient's experience. Finally, we evaluate how upcoming trial design and clinical practice are evolving in the face of MRD-driven outcomes.
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Affiliation(s)
- A. Fisher
- Division of Cancer Studies and Pathology, University of Leeds, Leeds, United Kingdom
- Department of Haematology, Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
| | - H. Goradia
- Department of Haematology, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - N. Martinez-Calle
- Department of Haematology, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - PEM. Patten
- Department of Haematology, Kings College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
- Comprehensive Cancer Centre, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - T. Munir
- Department of Haematology, Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
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11
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Wierda WG, Kipps TJ, Al-Sawaf O, Chyla B, Biondo JML, Mun Y, Jiang Y, Seymour JF. Utility of measurable residual disease for predicting treatment outcomes with BCR- and BCL2-Targeted therapies in patients with CLL. Leuk Lymphoma 2022; 63:2765-2784. [PMID: 35983732 DOI: 10.1080/10428194.2022.2098291] [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] [Received: 05/27/2022] [Accepted: 06/27/2022] [Indexed: 12/14/2022]
Abstract
Inhibitors targeting B-cell receptor (BCR) signaling pathway proteins and B-cell lymphoma-2 (BCL2) in chronic lymphocytic leukemia (CLL) are recommended in the first-line and relapsed/refractory disease settings. Measurable residual disease (MRD) is an important prognostic tool in patients treated with the BCL2-targeted agent, venetoclax. We explored the relationship between MRD status and progression-free (PFS)/overall survival (OS) in patients with CLL, following treatment with novel BCR- and BCL2-targeted agents. Compared with chemoimmunotherapy, higher rates of undetectable (u)MRD were achieved with BCL2-targeted therapies; achieving uMRD status was associated with longer PFS and OS than MRD-positivity. Continuous treatment with BCR-targeted agents did not achieve uMRD status in many patients, and outcomes were not correlated with uMRD status. Future clinical trials of targeted treatment combinations could be designed to demonstrate uMRD as a treatment objective, and allow a response-driven, personalized strategy to optimize treatment and improve OS outcomes.
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Affiliation(s)
| | | | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne Aachen Cologne Bonn Düsseldorf, German CLL Study Group, University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Yong Mun
- Genentech, Inc., South San Francisco, CA, USA
| | | | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
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12
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Fürstenau M, Weiss J, Giza A, Franzen F, Robrecht S, Fink AM, Fischer K, Schneider C, Tausch E, Stilgenbauer S, Ritgen M, Schilhabel A, Brüggemann M, Eichhorst B, Hallek M, Cramer P. Circulating Tumor DNA-Based MRD Assessment in Patients with CLL Treated with Obinutuzumab, Acalabrutinib, and Venetoclax. Clin Cancer Res 2022; 28:4203-4211. [PMID: 35594173 DOI: 10.1158/1078-0432.ccr-22-0433] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/12/2022] [Accepted: 05/17/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE With the advent of highly efficacious time-limited combination treatments of targeted agents in chronic lymphocytic leukemia (CLL), minimal residual disease (MRD) assessment has gained importance as a measure for therapeutic success and as a surrogate for progression-free survival. The currently most widely used method is multicolor flow cytometry, which detects circulating CLL cells in the peripheral blood. However, it seems to be less sensitive for the detection of MRD in the lymph node compartment. PATIENTS AND METHODS To evaluate whether a cell-free approach can overcome this limitation, we performed serial assessments of circulating tumor DNA (ctDNA) in patients with CLL treated with obinutuzumab, acalabrutinib, and venetoclax in the phase II CLL2-BAAG trial. Patient-specific variability, diversity, joining (VDJ) rearrangements as well as somatic driver mutations were tracked before, during and after treatment by digital droplet PCR in blood plasma. Furthermore, these were systematically compared to matched flow cytometry data. RESULTS In the 381 sample pairs, ctDNA and flow cytometry yielded highly concordant results. However, clone-specific ctDNA was detected in 44 of 152 samples (29%) that were assessed as undetectable MRD (uMRD) by flow cytometry (defined as less than one CLL cell in 10,000 normal leukocytes). 29 ctDNA-negative samples showed detectable MRD >10-4 by flow cytometry. Also, somatic driver mutations were detected with a similar sensitivity compared with patient-specific VDJ rearrangements in plasma. In patients with predominantly nodal residual disease, ctDNA compared favorably with 4-color flow cytometry and seemed to more accurately reflect the entire disease burden across compartments. CONCLUSIONS On the basis of these findings, ctDNA-based MRD assessment appears to be a promising method to complement cell-based MRD approaches like flow cytometry that focus on circulating CLL cells in the peripheral blood.
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MESH Headings
- Antibodies, Monoclonal, Humanized
- Benzamides
- Bridged Bicyclo Compounds, Heterocyclic
- Circulating Tumor DNA/genetics
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/drug therapy
- Neoplasm, Residual/genetics
- Pyrazines
- Sulfonamides
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Affiliation(s)
- Moritz Fürstenau
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jonathan Weiss
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Fabian Franzen
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christof Schneider
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Matthias Ritgen
- Department of Internal Medicine II, Faculty of Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anke Schilhabel
- Department of Internal Medicine II, Faculty of Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Monika Brüggemann
- Department of Internal Medicine II, Faculty of Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne and Dusseldorf, German CLL Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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13
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Lovell AR, Jammal N, Bose P. Selecting the optimal BTK inhibitor therapy in CLL: rationale and practical considerations. Ther Adv Hematol 2022; 13:20406207221116577. [PMID: 35966045 PMCID: PMC9373150 DOI: 10.1177/20406207221116577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) inhibitors have dramatically changed the treatment
of newly diagnosed and relapsed/refractory chronic lymphocytic leukemia (CLL).
Ibrutinib, acalabrutinib, and zanubrutinib are Food and Drug Administration
(FDA)-approved BTK inhibitors that have all demonstrated progression-free
survival (PFS) benefit compared with chemoimmunotherapy. The efficacy of these
agents compared to one another is under study; however, current data suggest
they provide similar efficacy. Selectivity for BTK confers different adverse
effect profiles, and longer follow-up and real-world use have characterized side
effects over time. The choice of BTK inhibitor is largely patient-specific, and
this review aims to highlight the differences among the agents and guide the
choice of BTK inhibitor in clinical practice.
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Affiliation(s)
- Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadya Jammal
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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14
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Tam CS, Allan JN, Siddiqi T, Kipps TJ, Jacobs R, Opat S, Barr PM, Tedeschi A, Trentin L, Bannerji R, Jackson S, Kuss BJ, Moreno C, Szafer-Glusman E, Russell K, Zhou C, Ninomoto J, Dean JP, Wierda WG, Ghia P. Fixed-duration ibrutinib plus venetoclax for first-line treatment of CLL: primary analysis of the CAPTIVATE FD cohort. Blood 2022; 139:3278-3289. [PMID: 35196370 PMCID: PMC11022982 DOI: 10.1182/blood.2021014488] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/11/2022] [Indexed: 11/20/2022] Open
Abstract
CAPTIVATE (NCT02910583) is an international phase 2 study in patients aged ≤70 years with previously untreated chronic lymphocytic leukemia (CLL). Results from the cohort investigating fixed-duration (FD) treatment with ibrutinib plus venetoclax are reported. Patients received 3 cycles of ibrutinib lead-in then 12 cycles of ibrutinib plus venetoclax (oral ibrutinib [420 mg/d]; oral venetoclax [5-week ramp-up to 400 mg/d]). The primary endpoint was complete response (CR) rate. Hypothesis testing was performed for patients without del(17p) with prespecified analyses in all treated patients. Secondary endpoints included undetectable minimal residual disease (uMRD) rates, progression-free survival (PFS), overall survival (OS), and safety. Of the 159 patients enrolled and treated, 136 were without del(17p). The median time on study was 27.9 months, and 92% of patients completed all planned treatment. The primary endpoint was met, with a CR rate of 56% (95% confidence interval [CI], 48-64) in patients without del(17p), significantly higher than the prespecified 37% minimum rate (P < .0001). In the all-treated population, CR rate was 55% (95% CI, 48-63); best uMRD rates were 77% (peripheral blood [PB]) and 60% (bone marrow [BM]); 24-month PFS and OS rates were 95% and 98%, respectively. At baseline, 21% of patients were in the high tumor burden category for tumor lysis syndrome (TLS) risk; after ibrutinib lead-in, only 1% remained in this category. The most common grade ≥3 adverse events (AEs) were neutropenia (33%) and hypertension (6%). First-line ibrutinib plus venetoclax represents the first all-oral, once-daily, chemotherapy-free FD regimen for patients with CLL. FD ibrutinib plus venetoclax achieved deep, durable responses and promising PFS, including in patients with high-risk features.
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Affiliation(s)
- Constantine S. Tam
- Peter MacCallum Cancer Center, Melbourne, VIC, Australia
- St. Vincent's Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | | | | | - Thomas J. Kipps
- Moores Cancer Center, University of California San Diego, San Diego, CA
| | | | | | - Paul M. Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | | | - Rajat Bannerji
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Bryone J. Kuss
- Flinders University and Medical Center, Bedford Park, SA, Australia
| | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | | | | | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - Joi Ninomoto
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - William G. Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paolo Ghia
- Università Vita-Salute San Raffaele, Milan, Italy
- IRCCS Ospedale San Raffaele, Milan, Italy
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15
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Salama ME, Otteson GE, Camp JJ, Seheult JN, Jevremovic D, Holmes DR, Olteanu H, Shi M. Artificial Intelligence Enhances Diagnostic Flow Cytometry Workflow in the Detection of Minimal Residual Disease of Chronic Lymphocytic Leukemia. Cancers (Basel) 2022; 14:cancers14102537. [PMID: 35626140 PMCID: PMC9139233 DOI: 10.3390/cancers14102537] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/17/2022] [Accepted: 05/18/2022] [Indexed: 02/05/2023] Open
Abstract
Flow cytometric (FC) immunophenotyping is critical but time-consuming in diagnosing minimal residual disease (MRD). We evaluated whether human-in-the-loop artificial intelligence (AI) could improve the efficiency of clinical laboratories in detecting MRD in chronic lymphocytic leukemia (CLL). We developed deep neural networks (DNN) that were trained on a 10-color CLL MRD panel from treated CLL patients, including DNN trained on the full cohort of 202 patients (F-DNN) and DNN trained on 138 patients with low-event cases (MRD < 1000 events) (L-DNN). A hybrid DNN approach was utilized, with F-DNN and L-DNN applied sequentially to cases. “Ground truth” classification of CLL MRD was confirmed by expert analysis. The hybrid DNN approach demonstrated an overall accuracy of 97.1% (95% CI: 84.7−99.9%) in an independent cohort of 34 unknown samples. When CLL cells were reported as a percentage of total white blood cells, there was excellent correlation between the DNN and expert analysis [r > 0.999; Passing−Bablok slope = 0.997 (95% CI: 0.988−0.999) and intercept = 0.001 (95% CI: 0.000−0.001)]. Gating time was dramatically reduced to 12 s/case by DNN from 15 min/case by the manual process. The proposed DNN demonstrated high accuracy in CLL MRD detection and significantly improved workflow efficiency. Additional clinical validation is needed before it can be fully integrated into the existing clinical laboratory practice.
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Affiliation(s)
- Mohamed E. Salama
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
| | - Gregory E. Otteson
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
| | - Jon J. Camp
- Biomedical Imaging, Mayo Clinic, Rochester, MN 55905, USA; (J.J.C.); (D.R.H.III)
| | - Jansen N. Seheult
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
| | - Dragan Jevremovic
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
| | - David R. Holmes
- Biomedical Imaging, Mayo Clinic, Rochester, MN 55905, USA; (J.J.C.); (D.R.H.III)
| | - Horatiu Olteanu
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
| | - Min Shi
- Division of Hematopathology, Mayo Clinic, Rochester, MN 55905, USA; (M.E.S.); (G.E.O.); (J.N.S.); (D.J.); (H.O.)
- Correspondence: ; Tel.: +1-507-284-2396
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16
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Colmenares R, Álvarez N, Barrio S, Martínez-López J, Ayala R. The Minimal Residual Disease Using Liquid Biopsies in Hematological Malignancies. Cancers (Basel) 2022; 14:cancers14051310. [PMID: 35267616 PMCID: PMC8909350 DOI: 10.3390/cancers14051310] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Monitoring the response to treatment in hematologic malignancies is essential in defining the best way to optimize patient management. In general, achieving a deeper response has been shown to lead to a better prognosis, and the techniques used to study the minimal residual disease (MRD) are becoming more precise. The use of liquid biopsies, that is, analyzing the presence of alterations in nucleic acids, usually in peripheral blood or other biological fluids, is being studied and optimized with increasingly innovative molecular techniques, such as next-generation sequencing (NGS) in the monitoring of the MRD, avoiding, in many cases, more invasive tests in different hematological neoplasms. Currently, liquid biopsies are not standardized for the MRD monitoring, but there is increasing evidence of its correlation with other techniques to measure responses to treatments and patient outcomes. Abstract The study of cell-free DNA (cfDNA) and other peripheral blood components (known as “liquid biopsies”) is promising, and has been investigated especially in solid tumors. Nevertheless, it is increasingly showing a greater utility in the diagnosis, prognosis, and response to treatment of hematological malignancies; in the future, it could prevent invasive techniques, such as bone marrow (BM) biopsies. Most of the studies about this topic have focused on B-cell lymphoid malignancies; some of them have shown that cfDNA can be used as a novel way for the diagnosis and minimal residual monitoring of B-cell lymphomas, using techniques such as next-generation sequencing (NGS). In myelodysplastic syndromes, multiple myeloma, or chronic lymphocytic leukemia, liquid biopsies may allow for an interesting genomic representation of the tumor clones affecting different lesions (spatial heterogeneity). In acute leukemias, it can be helpful in the monitoring of the early treatment response and the prediction of treatment failure. In chronic lymphocytic leukemia, the evaluation of cfDNA permits the definition of clonal evolution and drug resistance in real time. However, there are limitations, such as the difficulty in obtaining sufficient circulating tumor DNA for achieving a high sensitivity to assess the minimal residual disease, or the lack of standardization of the method, and clinical studies, to confirm its prognostic impact. This review focuses on the clinical applications of cfDNA on the minimal residual disease in hematological malignancies.
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Affiliation(s)
- Rafael Colmenares
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (R.C.); (N.Á.); (S.B.); (J.M.-L.)
| | - Noemí Álvarez
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (R.C.); (N.Á.); (S.B.); (J.M.-L.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
| | - Santiago Barrio
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (R.C.); (N.Á.); (S.B.); (J.M.-L.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
| | - Joaquín Martínez-López
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (R.C.); (N.Á.); (S.B.); (J.M.-L.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
- Department of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain
| | - Rosa Ayala
- Hematology Department, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Imas12, 28041 Madrid, Spain; (R.C.); (N.Á.); (S.B.); (J.M.-L.)
- Hematological Malignancies Clinical Research Unit, CNIO, 28029 Madrid, Spain
- Department of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-9-1779-2788
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17
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Jain N, Thompson P, Burger J, Ferrajoli A, Takahashi K, Estrov Z, Borthakur G, Bose P, Kadia T, Pemmaraju N, Sasaki K, Konopleva M, Jabbour E, Garg N, Wang X, Kanagal-Shamanna R, Patel K, Wang W, Jorgensen J, Wang S, Lopez W, Ayala A, Plunkett W, Gandhi V, Kantarjian H, O'Brien S, Keating M, Wierda WG. Ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) regimen for chronic lymphocytic leukemia (CLL) with mutated IGHV and without TP53 aberrations. Leukemia 2021; 35:3421-3429. [PMID: 34007049 DOI: 10.1038/s41375-021-01280-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/20/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
Chemoimmunotherapy with combined fludarabine, cyclophosphamide and rituximab (FCR) has been an effective treatment for patients with chronic lymphocytic leukemia (CLL). We initiated a phase II trial for previously untreated patients with CLL with mutated IGHV and absence of del(17p)/TP53 mutation. Patients received ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) for three cycles. Patients who achieved complete remission (CR)/CR with incomplete count recvoery (CRi) with marrow undetectable measurable residual disease (U-MRD) received additional nine cycles of ibrutinib with three cycles of obinutuzumab; all others received nine additional cycles of ibrutinib and obinutuzumab. Patients in marrow U-MRD remission after cycle 12 discontinued all treatment, including ibrutinib. Forty-five patients were treated. The median follow-up is 41.3 months. Among the total 45 treated patients, after three cycles, 38% achieved CR/CRi and 87% achieved marrow U-MRD. After cycle 12, the corresponding numbers were 67% and 91%, respectively. Overall, 44/45 (98%) patients achieved marrow U-MRD as best response. No patient had CLL progression. The 3-year progression-free survival (PFS) and overall survival (OS) were 98% and 98%, respectively. Per trial design, all patients who completed cycle 12 discontinued ibrutinib, providing for a time-limited therapy. Grade 3-4 neutropenia and thrombocytopenia occurred in 58% and 40% patients, respectively. The iFCG regimen with only 3 cycles of chemotherapy is an effective, time-limited regimen for patients with CLL with mutated IGHV and without del(17p)/TP53 mutation.
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MESH Headings
- Adenine/administration & dosage
- Adenine/analogs & derivatives
- Adult
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor
- Cyclophosphamide/administration & dosage
- Female
- Follow-Up Studies
- Humans
- Immunoglobulin Heavy Chains/genetics
- Immunoglobulin Variable Region/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Mutation
- Piperidines/administration & dosage
- Prognosis
- Survival Rate
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Garg
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wanda Lopez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ana Ayala
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Plunkett
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Varsha Gandhi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA, USA
| | - Michael Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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18
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Wierda WG, Allan JN, Siddiqi T, Kipps TJ, Opat S, Tedeschi A, Badoux XC, Kuss BJ, Jackson S, Moreno C, Jacobs R, Pagel JM, Flinn I, Pak Y, Zhou C, Szafer-Glusman E, Ninomoto J, Dean JP, James DF, Ghia P, Tam CS. Ibrutinib Plus Venetoclax for First-Line Treatment of Chronic Lymphocytic Leukemia: Primary Analysis Results From the Minimal Residual Disease Cohort of the Randomized Phase II CAPTIVATE Study. J Clin Oncol 2021; 39:3853-3865. [PMID: 34618601 PMCID: PMC8713593 DOI: 10.1200/jco.21.00807] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
PURPOSE CAPTIVATE (NCT02910583), a randomized phase II study, evaluates minimal residual disease (MRD)-guided treatment discontinuation following completion of first-line ibrutinib plus venetoclax treatment in patients with chronic lymphocytic leukemia (CLL). METHODS Previously untreated CLL patients age < 70 years received three cycles of ibrutinib and then 12 cycles of combined ibrutinib plus venetoclax. Patients in the MRD cohort who met the stringent random assignment criteria for confirmed undetectable MRD (Confirmed uMRD) were randomly assigned 1:1 to double-blind placebo or ibrutinib; patients without Confirmed uMRD (uMRD Not Confirmed) were randomly assigned 1:1 to open-label ibrutinib or ibrutinib plus venetoclax. Primary end point was 1-year disease-free survival (DFS) rate with placebo versus ibrutinib in the Confirmed uMRD population. Secondary end points included response rates, uMRD, and safety. RESULTS One hundred sixty-four patients initiated three cycles of ibrutinib lead-in. After 12 cycles of ibrutinib plus venetoclax, best uMRD response rates were 75% (peripheral blood) and 68% (bone marrow). Patients with Confirmed uMRD were randomly assigned to receive placebo (n = 43) or ibrutinib (n = 43); patients with uMRD Not Confirmed were randomly assigned to ibrutinib (n = 31) or ibrutinib plus venetoclax (n = 32). Median follow-up was 31.3 months. One-year DFS rate was not significantly different between placebo (95%) and ibrutinib (100%; arm difference: 4.7% [95% CI, -1.6 to 10.9]; P = .15) in the Confirmed uMRD population. After ibrutinib lead-in tumor debulking, 36 of 40 patients (90%) with high tumor lysis syndrome risk at baseline shifted to medium or low tumor lysis syndrome risk categories. Adverse events were most frequent during the first 6 months of ibrutinib plus venetoclax and generally decreased over time. CONCLUSION The 1-year DFS rate of 95% in placebo-randomly assigned patients with Confirmed uMRD suggests the potential for fixed-duration treatment with this all-oral, once-daily, chemotherapy-free regimen in first-line CLL.
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Affiliation(s)
- William G Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | - Bryone J Kuss
- Flinders University and Medical Centre, Bedford Park, SA, Australia
| | | | - Carol Moreno
- Hospital de la Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | | | - John M Pagel
- Swedish Cancer Institute Center for Blood Disorders and Stem Cell Transplantation, Seattle, WA
| | - Ian Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN
| | - Yvonne Pak
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - Joi Ninomoto
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - James P Dean
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Constantine S Tam
- Peter MacCallum Cancer Center and St Vincent's Hospital and the University of Melbourne, Melbourne, VIC, Australia
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19
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Wierda WG, Rawstron A, Cymbalista F, Badoux X, Rossi D, Brown JR, Egle A, Abello V, Cervera Ceballos E, Herishanu Y, Mulligan SP, Niemann CU, Diong CP, Soysal T, Suzuki R, Tran HTT, Wu SJ, Owen C, Stilgenbauer S, Ghia P, Hillmen P. Measurable residual disease in chronic lymphocytic leukemia: expert review and consensus recommendations. Leukemia 2021; 35:3059-3072. [PMID: 34168283 PMCID: PMC8550962 DOI: 10.1038/s41375-021-01241-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022]
Abstract
Assessment of measurable residual disease (often referred to as "minimal residual disease") has emerged as a highly sensitive indicator of disease burden during and at the end of treatment and has been correlated with time-to-event outcomes in chronic lymphocytic leukemia. Undetectable-measurable residual disease status at the end of treatment demonstrated independent prognostic significance in chronic lymphocytic leukemia, correlating with favorable progression-free and overall survival with chemoimmunotherapy. Given its utility in evaluating depth of response, determining measurable residual disease status is now a focus of outcomes in chronic lymphocytic leukemia clinical trials. Increased adoption of measurable residual disease assessment calls for standards for nomenclature and outcomes data reporting. In addition, many basic questions have not been systematically addressed. Here, we present the work of an international, multidisciplinary, 174-member panel convened to identify critical questions on key issues pertaining to measurable residual disease in chronic lymphocytic leukemia, review evaluable data, develop unified answers in conjunction with local expert input, and provide recommendations for future studies. Recommendations are presented regarding methodology for measurable residual disease determination, assay requirements and in which tissue to assess measurable residual disease, timing and frequency of assessment, use of measurable residual disease in clinical practice versus clinical trials, and the future usefulness of measurable residual disease assessment. Nomenclature is also proposed. Adoption of these recommendations will work toward standardizing data acquisition and interpretation in future studies with new treatments with the ultimate objective of improving outcomes and curing chronic lymphocytic leukemia.
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Affiliation(s)
| | | | - Florence Cymbalista
- Hôpital Avicenne, AP-HP, UMR Université Paris13/INSERM U978, Bobigny, France
| | | | - Davide Rossi
- Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Jennifer R Brown
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Alexander Egle
- Department of Internal Medicine III with Haematology, Medical Oncology, Hemostaseology, Infectiology and Rheumatology, Oncologic Center, Paracelsus Medical University, Salzburg, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Salzburg, Austria
| | | | | | - Yair Herishanu
- Tel-Aviv Sourasky Medical Center and Sackler Medical School, Tel Aviv, Israel
| | | | | | | | - Teoman Soysal
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | - Shang-Ju Wu
- National Taiwan University Hospital, Taipei, Taiwan
| | | | - Stephan Stilgenbauer
- Internal Medicine III, Ulm University, Ulm and Internal Medicine 1, Saarland University, Homburg, Germany
| | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
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20
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A fixed-duration, measurable residual disease-guided approach in CLL: follow-up data from the phase 2 ICLL-07 FILO trial. Blood 2021; 137:1019-1023. [PMID: 33167024 DOI: 10.1182/blood.2020008164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/07/2020] [Indexed: 11/20/2022] Open
Abstract
Trials assessing first-line, fixed-duration approaches in chronic lymphocytic leukemia (CLL) are yielding promising activity, but few long-term data are available. We report follow-up data from a phase 2 trial (ICLL07 FILO) in previously untreated, medically fit patients (N = 135). Patients underwent obinutuzumab-ibrutinib induction for 9 months; then, following evaluation (N = 130 evaluable), those in complete remission and with bone marrow measurable residual disease (BM MRD) <0.01% (n = 10) received ibrutinib for 6 additional months; those in partial remission and/or with BM MRD ≥0.01%, the majority (n = 120), also received 4 cycles of immunochemotherapy (fludarabine/cyclophosphamide-obinutuzumab). Beyond end of treatment, responses were assessed every 3 month and peripheral blood MRD every 6 months. At median follow-up 36.7 months from treatment start, progression-free and overall survival rates (95% confidence interval) at 3 years were 95.7% (92.0% to 99.5%) and 98% (95.1% to 100%), respectively. Peripheral blood MRD <0.01% rates were 97%, 96%, 90%, 84%, and 89% at months 16, 22, 28, 34, and 40, respectively. No new treatment-related or serious adverse event occurred beyond end of treatment. Thus, in previously untreated, medically fit patients with CLL, a fixed-duration (15 months), MRD-guided approach achieved high survival rates, a persistent MRD benefit beyond the end of treatment, and low long-term toxicity. This trial was registered at www.clinicaltrials.gov as #NCT02666898.
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21
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Venetoclax alone or in combination with other regimens treatment achieve deep and sustained remission of relapsed/refractory chronic lymphocytic leukemia: a meta-analysis. Clin Exp Med 2021; 22:161-171. [PMID: 34224006 DOI: 10.1007/s10238-021-00739-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/24/2021] [Indexed: 12/23/2022]
Abstract
Recently, the use of novel targeted drugs significantly improved the overall response rate (ORR) and survival of patients with relapsed/refractory chronic lymphocytic leukemia (R/R CLL). The treatment of R/R CLL has been gradually developed from traditional chemotherapy to targeted therapy. Venetoclax has been proved to be effective for R/R CLL as a single agent or in combination with various regimens. However, the data from clinical studies were still limited, especially since a large number of studies were single arms. Considering that there were few kinds of research in this regard and the data were not uniform, a meta-analysis was conducted to describe ORR and undetectable minimal residual disease (uMRD) of venetoclax in patients with R/R CLL. The pooled cumulative prevalence of total ORR was 82% (95% CI 77-87%), and the pooled ORR in venetoclax + anti-CD20 antibody-based group was 89% (95% CI 83-94%). There were significant differences among venetoclax monotherapy group, venetoclax + ibrutinib group and venetoclax + anti-CD20 group with pooled uMRD of 39% (95% CI 31-47%), 57% (95% CI 50-64%) and 43% (95% CI 19-70%), respectively (P = 0.004 < 0.05). Pooled ORR of patients with high-risk cytogenetic in venetoclax monotherapy group was 73% (95% CI 61-83%). No significant difference was observed in comparison with patients without high-risk cytogenetic who received the same treatment (P = 0.518). Our research results indicate that venetoclax combined with anti-CD20 monoclonal antibody may be an effective treatment for patients with R/R CLL, especially for CLL patients with high-risk cytogenetic factors. Furthermore, ibrutinib in combination with venetoclax showed a longer remission time, the deeper remission degree and uMRD-negative rate gradually increased with the extension of the treatment time.
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22
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Immune Gene Rearrangements: Unique Signatures for Tracing Physiological Lymphocytes and Leukemic Cells. Genes (Basel) 2021; 12:genes12070979. [PMID: 34198966 PMCID: PMC8329920 DOI: 10.3390/genes12070979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/25/2021] [Indexed: 02/07/2023] Open
Abstract
The tremendous diversity of the human immune repertoire, fundamental for the defense against highly heterogeneous pathogens, is based on the ingenious mechanism of immune gene rearrangements. Rearranged immune genes encoding the immunoglobulins and T-cell receptors and thus determining each lymphocyte's antigen specificity are very valuable molecular markers for tracing malignant or physiological lymphocytes. One of their most significant applications is tracking residual leukemic cells in patients with lymphoid malignancies. This so called 'minimal residual disease' (MRD) has been shown to be the most important prognostic factor across various leukemia subtypes and has therefore been given enormous attention. Despite the current rapid development of the molecular methods, the classical real-time PCR based approach is still being regarded as the standard method for molecular MRD detection due to the cumbersome standardization of the novel approaches currently in progress within the EuroMRD and EuroClonality NGS Consortia. Each of the molecular methods, however, poses certain benefits and it is therefore expectable that none of the methods for MRD detection will clearly prevail over the others in the near future.
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23
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Al-Sawaf O, Seymour JF, Kater AP, Fischer K. Should Undetectable Minimal Residual Disease Be the Goal of Chronic Lymphocytic Leukemia Therapy? Hematol Oncol Clin North Am 2021; 35:775-791. [PMID: 34102145 DOI: 10.1016/j.hoc.2021.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With the advent of highly effective novel therapies for chronic lymphocytic leukemia, conventional response assessment is not able to sensitively capture depth of response. To achieve a more precise assessment of response, minimal residual disease has been introduced to more accurately classify and quantify treatment outcomes. It is now considered a strong predictor of outcome in chronic lymphocytic leukemia, although its interpretation depends on the therapeutic context. This review discusses available methods of minimal residual disease measurement. It summarizes minimal residual disease data from pivotal clinical trials and discusses potential implications for future studies and minimal residual disease-based clinical strategies.
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Affiliation(s)
- Othman Al-Sawaf
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
| | - John F Seymour
- Department of Hematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Research Center Amsterdam (LYMMCARE), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Kirsten Fischer
- Department of Internal Medicine, Center of Integrated Oncology Cologne Bonn, University Hospital, German CLL Study Group, Gleueler Strasse 176, 50935 Cologne, Germany
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24
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Stance of MRD in Non-Hodgkin's Lymphoma and its upsurge in the novel era of cell-free DNA. Clin Transl Oncol 2021; 23:2206-2219. [PMID: 33991328 DOI: 10.1007/s12094-021-02635-4] [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: 02/12/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
Cancer genomics has evolved over the years from understanding the pathogenesis of cancer to screening the future possibilities of cancer occurrence. Understanding the genetic profile of tumors holds a prognostic as well as a predictive value in this era of therapeutic surveillance, molecular remission, and precision medicine. Identifying molecular markers in tumors is the current standard of approach, and requires an efficient combination of an accessible sample type and a profoundly sensitive technique. Liquid biopsy or cell-free DNA has evolved as a novel sample type with promising results in recent years. Although cell-free DNA has significant role in various cancer types, this review focuses on its application in Non-Hodgkin's Lymphoma. Beginning with the current concept and clinical relevance of minimal residual disease in Non-Hodgkin's lymphoma, we discuss the literature on circulating DNA and its evolving application in the realm of cutting-edge technology.
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25
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Patel K, Pagel JM. Current and future treatment strategies in chronic lymphocytic leukemia. J Hematol Oncol 2021; 14:69. [PMID: 33902665 PMCID: PMC8074228 DOI: 10.1186/s13045-021-01054-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
Treatment decisions for patients with chronic lymphocytic leukemia (CLL) are dependent on symptoms and classification into high-, medium-, or low-risk categories. The prognosis for CLL hinges, in part, on the presence or absence of less-favorable genetic aberrations, including del(17p), del(11q), TP53 dysfunction, and IGHV mutations, as these markers are associated with worse treatment response. Promising results from multiple clinical trials show emerging therapies targeting Burton tyrosine kinase, B-cell leukemia/lymphoma 2, and phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit delta result in better outcomes and prolonged progression-free survival for patients both with and without certain high-risk aberrations. Favorable outcomes using these novel oral targeted therapies, either alone or in combination with other treatments such as anti-CD20 antibodies, has led to their use almost entirely supplanting chemoimmunotherapy in the treatment of CLL. In this narrative review, we summarize the current clinical evidence for the use of targeted mono- and combination therapies for CLL, discuss new and next-generation treatment approaches currently in development, and provide insight into areas of unmet need for the treatment of patients with CLL.
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Affiliation(s)
- Krish Patel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA.
| | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
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26
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Hampel PJ, Parikh SA, Call TG. Incorporating molecular biomarkers into the continuum of care in chronic lymphocytic leukemia. Leuk Lymphoma 2021; 62:1289-1301. [PMID: 33410372 DOI: 10.1080/10428194.2020.1869966] [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: 10/22/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is a mature B-cell malignancy characterized by marked heterogeneity. Discoveries in disease biology over the past two decades have helped explain clinical variability and heralded the arrival of the targeted therapy era. In this article, we review improvements in risk stratification which have coincided with this progress, including individual biomarkers and their incorporation into prognostic models. Amidst an ever-expanding list of biomarkers, we seek to bring focus to the essential tests to improve patient care and counseling at particular times in the disease course, beginning with prognosis at diagnosis. The majority of patients do not require treatment at the time of diagnosis, making time-to-first-treatment a key initial prognostic concern. Prognostic and predictive biomarkers are then considered at subsequent major junctures, including at the time of treatment initiation, while on therapy, and at the time of relapse on novel agents.
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Affiliation(s)
- Paul J Hampel
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Timothy G Call
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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27
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Farren TW, Sadanand KS, Agrawal SG. Highly Sensitive and Accurate Assessment of Minimal Residual Disease in Chronic Lymphocytic Leukemia Using the Novel CD160-ROR1 Assay. Front Oncol 2020; 10:597730. [PMID: 33344247 PMCID: PMC7744938 DOI: 10.3389/fonc.2020.597730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022] Open
Abstract
Undetectable minimal residual disease (MRD) in Chronic Lymphocytic Leukemia (CLL) has a favorable prognostic outcome compared with MRD that can be detected. This study investigated a flow cytometric assay (CD160-ROR1FCA) targeting the tumor-specific antigens CD160 and receptor tyrosine kinase-like orphan receptor 1 (ROR1), along with CD2, CD5, CD19, CD45. CD160-ROR1FCA was compared with the originally published 8-colour European Research Initiative for CLL (ERIC) gold-standard assay for CLL MRD detection. CD160-ROR1FCA had a limit of detection of 0.001% and showed strong correlation with ERIC (R = 0.98, p < 0.01) with negligible differences in MRD detection (bias -0.3152 95%CI 5.586 to -6.216). Using CD160-ROR1FCA, increased expression of both CD160 and ROR1 was found in Monoclonal B cell Lymphocytosis (MBL) compared to low-level polyclonal B-cell expansions (p < 0.01). Patients in CR and with undetectable MRD had a longer EFS (not reached) than those in CR but with detectable MRD (756 days, p < 0.01) versus 113 days in patients with partial remission (p < 0.01). Patients with MRD levels of >0.01 to 0.1% had a longer EFS (2,333 days), versus levels between 0.1 to 1% (1,049 days). CD160-ROR1FCA is a novel assay for routine CLL MRD measurement and for MBL detection. MRD status assessed by CD160-ROR1FCA after CLL treatment correlated with EFS.
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Affiliation(s)
- Timothy W Farren
- Department of Haemato-Oncology and Immunophenotyping (SIHMDS), Barts Health NHS Trust, London, United Kingdom.,Immunobiology, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Kaushik S Sadanand
- Immunobiology, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Samir G Agrawal
- Department of Haemato-Oncology and Immunophenotyping (SIHMDS), Barts Health NHS Trust, London, United Kingdom.,Immunobiology, Blizard Institute, Queen Mary University of London, London, United Kingdom
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28
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Lee JC, Lamanna N. Is There a Role for Chemotherapy in the Era of Targeted Therapies? Curr Hematol Malig Rep 2020; 15:72-82. [PMID: 32107713 DOI: 10.1007/s11899-020-00563-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The treatment landscape of chronic lymphocytic leukemia has been rapidly evolving over the past few years. The prior standard of care, chemoimmunotherapy, is being replaced by targeted agents, and the utility of chemotherapy has come under question. In this review, we examine recent data comparing chemoimmunotherapy to targeted agents, how these data impact clinical management, and whether there are potential future roles for cytotoxic chemotherapy. RECENT FINDINGS Clinical trials have shown improved clinical outcomes with targeted agents compared to traditional chemoimmunotherapy. Based on these data, the current treatment paradigm primarily favors targeted agents over chemoimmunotherapy, with a few exceptions. However, targeted agents have notable limitations, and thus, there may be a future role of cytotoxic chemotherapy when administered in combination with targeted agents. Although targeted agents have nearly replaced chemoimmunotherapy in the treatment of chronic lymphocytic leukemia, novel combinations utilizing chemotherapy are being developed that may lead to better outcomes.
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Affiliation(s)
| | - Nicole Lamanna
- Columbia University Medical Center, NY, USA. .,Associate Attending, Leukemia Service, Director of the Chronic Lymphocytic Leukemia Program, Hematologic Malignancies Section, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian/Columbia University Medical Center, NY, USA.
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29
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Kojima K, Burger JA. Treatment algorithm for Japanese patients with chronic lymphocytic leukemia in the era of novel targeted therapies. J Clin Exp Hematop 2020; 60:130-137. [PMID: 32404571 PMCID: PMC7810251 DOI: 10.3960/jslrt.20002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Treatment for patients with chronic lymphocytic leukemia (CLL) is becoming more individualized due to the recent introduction of novel molecularly targeted therapies into the therapeutic armamentarium. Genomic and molecular risk factors in CLL patients determine the individual risk for disease progression and response to therapy, and can impact survival. In this review article, we discuss current treatment strategies for CLL patients in Japan, where the novel targeted agents, the BTK inhibitor ibrutinib and BCL2 antagonist venetoclax, now are available and increasingly used in clinical practice. We also discuss the importance of CLL risk factors for making therapy decisions, focusing on immunoglobulin variable region heavy chain (IGHV) mutation status, 11q deletion, and 17p deletion. Treatment approaches for CLL have rapidly changed in the past few years because of these new targeted agents. They are highly effective, well tolerated, and have been demonstrated in a series of large randomized clinical trials to improve survival when compared with conventional chemotherapy-based treatment. Therefore, for most patients, especially high-risk CLL patients, BTK inhibitor and BCL2 antagonist therapies are preferred over chemo-immunotherapy. Currently ongoing studies seek to determine the best sequence for these new agents and whether a combination therapy approach is beneficial. With these developments, a new era of chemotherapy-free treatment for CLL patients is expected.
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Affiliation(s)
- Kensuke Kojima
- Department of Hematology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Prognostic value of high-sensitivity measurable residual disease assessment after front-line chemoimmunotherapy in chronic lymphocytic leukemia. Leukemia 2020; 35:1597-1609. [PMID: 32934355 DOI: 10.1038/s41375-020-01009-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/24/2020] [Accepted: 07/29/2020] [Indexed: 12/21/2022]
Abstract
Measurable residual disease (MRD) status is widely adopted in clinical trials in patients with chronic lymphocytic leukemia (CLL). Findings from FILO group trials (CLL2007FMP, CLL2007SA, CLL2010FMP) enabled investigation of the prognostic value of high-sensitivity (0.7 × 10-5) MRD assessment using flow cytometry, in blood (N = 401) and bone marrow (N = 339), after fludarabine, cyclophosphamide, and rituximab (FCR)-based chemoimmunotherapy in a homogeneous population with long follow-up (median 49.5 months). Addition of low-level positive MRD < 0.01% to MRD ≥ 0.01% increased the proportion of cases with positive MRD in blood by 39% and in bone marrow by 27%. Compared to low-level positive MRD < 0.01%, undetectable MRD was associated with significantly longer progression-free survival (PFS) when using blood (72.2 versus 42.7 months; hazard ratio 0.40, p = 0.0003), but not when using bone marrow. Upon further stratification, positive blood MRD at any level, compared to undetectable blood MRD, was associated with shorter PFS irrespective of clinical complete or partial remission, and a lower 5-year PFS rate irrespective of IGHV-mutated or -unmutated status (all p < 0.05). In conclusion, high-sensitivity (0.0007%) MRD assessment in blood yielded additional prognostic information beyond the current standard sensitivity (0.01%). Our approach provides a model for future determination of the optimal MRD investigative strategy for any regimen.
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Goshaw JM, Gao Q, Wardrope J, Dogan A, Roshal M. 14-Color single tube for flow cytometric characterization of CD5+ B-LPDs and high sensitivity automated minimal residual disease quantitation of CLL/SLL. CYTOMETRY PART B-CLINICAL CYTOMETRY 2020; 100:509-518. [PMID: 32896973 DOI: 10.1002/cyto.b.21953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/09/2020] [Accepted: 08/19/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION The diagnosis of CLL/SLL relies on flow cytometric immunophenotyping. Increasing emphasis is being placed on precise detection of the minimal residual disease. Following antigen recommendations of ERIC and ESCCA's Harmonization Project, we validated a 14-color assay for the characterization CD5+ lymphoproliferative neoplasms and CLL MRD with a sensitivity of at least 10-4 . METHODS The assay was designed based on ERIC/ESCCA recommended antigens with the addition of CD40 for alternate gating when CD19 expression is reduced. Lower limit of quantitation/lower limit of detection, assay procedural precision, linearity, and limit of blank were established. Then, 52 CD5+ B-cell lymphoproliferative neoplasms (41 CLL/11 non-CLL) and 29 normal samples were used for parallel evaluation. Automated cluster identification and quantitation of CLL clones in MRD setting was performed using Barned-Hutt SNE. Separation analysis between CLL and non-CLL phenotypes was performed by PCA and bh-SNE. RESULTS Separation ratios for each antigen exceeded ERIC/ESCCA guidelines. Precision was <20% at LLOQ (0.01%). The limit of blank was <10/500,000 cells. Concordance between the 14-color and legacy assay (Deming regression y = 1.01x, r2 = .99) was seen. All 20 samples with MRD levels 0.5%-0.006% (median 0.04%) showed an abnormal cell cluster by bh-SNE, with concordant results between manual and automated quantitation (y = x, r2 = 1). CLL cases clustered together and away from mantle cell lymphoma by bh-SNE and PCA with outlier atypical phenotype CLL cases posing diagnostic challenges by both manual and automated analysis. CONCLUSION The 14-color CD5+ LPD assay provides a robust standardization platform for MRD and disease characterization using both manual and automated analysis.
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Affiliation(s)
- Jennifer M Goshaw
- Memorial Sloan Kettering Cancer Center, Department of Pathology, Hematopathology Service, New York, New York, USA
| | - Qi Gao
- Memorial Sloan Kettering Cancer Center, Department of Pathology, Hematopathology Service, New York, New York, USA
| | - Jessica Wardrope
- Memorial Sloan Kettering Cancer Center, Department of Pathology, Hematopathology Service, New York, New York, USA
| | - Ahmet Dogan
- Memorial Sloan Kettering Cancer Center, Department of Pathology, Hematopathology Service, New York, New York, USA
| | - Mikhail Roshal
- Memorial Sloan Kettering Cancer Center, Department of Pathology, Hematopathology Service, New York, New York, USA
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Davids MS, Fisher DC, Tyekucheva S, McDonough M, Hanna J, Lee B, Francoeur K, Montegaard J, Odejide O, Armand P, Arnason J, Brown JR. A phase 1b/2 study of duvelisib in combination with FCR (DFCR) for frontline therapy for younger CLL patients. Leukemia 2020; 35:1064-1072. [PMID: 32820271 PMCID: PMC7895867 DOI: 10.1038/s41375-020-01010-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023]
Abstract
Fludarabine, cyclophosphamide, and rituximab (FCR) is highly effective initial therapy for younger patients with chronic lymphocytic leukemia (CLL); however, most eventually relapse. Duvelisib is a delta/gamma PI3K inhibitor approved for relapsed/refractory CLL. We conducted an investigator-initiated, phase 1b/2 study of duvelisib + FCR (DFCR) as initial treatment for CLL patients aged ≤65. A standard 3 + 3 design included two dose levels of duvelisib (25 mg qd and 25 mg bid). Duvelisib was given for 1 week, then with standard FCR added for up to six 28-day cycles, then up to 2 years of duvelisib maintenance. Thirty-two patients were enrolled. The phase 2 dose of duvelisib was identified as 25 mg bid. Hematologic toxicity was common, and all-grade non-hematologic toxicities included transaminitis (28%), febrile neutropenia (22%), pneumonia (19%), and colitis (6%). The best overall response rate by ITT was 88% (56% CR/CRi and 32% PR). The best rate of bone marrow undetectable minimal residual disease (BM-uMRD) by ITT was 66%. The rate of CR with BM-uMRD at end of combination treatment (primary endpoint) was 25%. Three-year PFS and OS are 73 and 93%, respectively. DFCR is active as initial therapy of younger CLL patients. Immune-mediated and infectious toxicities occurred and required active management.
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Affiliation(s)
- Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Svitlana Tyekucheva
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mikaela McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandon Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karen Francoeur
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Oreofe Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jon Arnason
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Abstract
The evaluation of minimal residual disease (MRD) in chronic lymphocytic leukemia (CLL) has evolved in parallel with the enormous progresses in the therapeutic armamentarium and the application of cutting-edge diagnostic techniques the CLL community witnessed in the past few years. Minimal residual disease is considered an objective measure of disease status defined by the number of residual leukemic cells detected in a sample of peripheral blood and/or bone marrow as proportion of the total white blood cells and defined undetectable if fewer than 1 CLL cell among 10,000 white blood cells (10 or 0.01%) is detected. In this review, we aim at shedding light on how to evaluate MRD, what we already know about MRD from the experience with chemoimmunotherapy, and why MRD evaluation remains still relevant in the era of targeted agents.
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Moia R, Patriarca A, Mahmoud AM, Ferri V, Favini C, Rasi S, Deambrogi C, Gaidano G. Assessing prognosis of chronic lymphocytic leukemia using biomarkers and genetics. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1804860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Andrea Patriarca
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Abdurraouf Mokhtar Mahmoud
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Valentina Ferri
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Chiara Favini
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Silvia Rasi
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Clara Deambrogi
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
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MESH Headings
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/history
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Drug Resistance, Neoplasm
- Female
- History, 20th Century
- History, 21st Century
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Mutation
- Prognosis
- Receptors, Antigen, B-Cell/genetics
- Receptors, Antigen, B-Cell/metabolism
- Signal Transduction
- Survival Rate
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Affiliation(s)
- Jan A Burger
- From the Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston
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Abstract
PURPOSE OF THIS REVIEW This review summarizes the role of BCL-2 in the pathogenesis of CLL, and the clinical data evaluating safety and efficacy of venetoclax, in treatment of patients with CLL, in the context of other available targeted agents. RECENT FINDINGS Venetoclax, alone or in combination with other targeted agents results in high rate of durable responses and undetectable measurable residual disease. Venetoclax maintains activity across all clinical and biologic subgroups, including those with high risk disease, including CLL with chromosome 17p deletion. TLS risk can be mitigated with risk stratification and five-week administration ramp-up schedule. Venetoclax, a novel, orally bioavailable inhibitor of BCL-2 has demonstrated substantial clinical activity in the treatment of CLL. In combination with other targeted agents it can induce high disease response rates and potentially lead to MRD-negative durable remissions.
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Affiliation(s)
- Herbert Eradat
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, CA, USA.
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How to manage lymphoid malignancies during novel 2019 coronavirus (CoVid-19) outbreak: a Brazilian task force recommendation. Hematol Transfus Cell Ther 2020; 42:103-110. [PMID: 32313873 PMCID: PMC7164906 DOI: 10.1016/j.htct.2020.04.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 02/06/2023] Open
Abstract
The novel Coronavirus (CoVid-19) outbreak is now consider a world pandemic, affecting more than 1,300,000 people worldwide. Cancer patients are in risk for severe disease, including a higher risk of intensive care unit (ICU) admission, need for invasive ventilation or death. Management of patients with lymphoid malignancies can be challenging during the outbreak, due to need of multiple hospital visits and admissions, immunosuppression and need for chemotherapy, radiotherapy and stem cell transplantation. In this article, we will focus on the practical management of patients with lymphoid malignancies during the COVID-19 pandemic, focusing on minimizing the risk for patients.
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Minimal residual disease undetectable by next-generation sequencing predicts improved outcome in CLL after chemoimmunotherapy. Blood 2020; 134:1951-1959. [PMID: 31537528 DOI: 10.1182/blood.2019001077] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) who achieve blood or bone marrow (BM) undetectable minimal residual disease (U-MRD) status after first-line fludarabine, cyclophosphamide, and rituximab (FCR) have prolonged progression-free survival (PFS), when assessed by an assay with sensitivity 10-4 (MRD4). Despite reaching U-MRD4, many patients, especially those with unmutated IGHV, subsequently relapse, suggesting residual disease <10-4 threshold and the need for more sensitive MRD evaluation. MRD evaluation by next-generation sequencing (NGS) has a sensitivity of 10-6 (MRD6). To better assess the depth of remission following first-line FCR treatment, we used NGS (Adaptive Biotechnologies Corporation) to assess MRD in 62 patients, all of whom had BM U-MRD by multicolor flow cytometry (sensitivity 10-4) at end-of-FCR treatment. Samples from these patients included 57 BM samples, 29 peripheral blood mononuclear cell (PBMC) samples, and 32 plasma samples. Only 27.4% of the 62 patients had U-MRD by NGS. Rate of U-MRD by NGS was lowest in BM (25%), compared with PBMC (55%) or plasma (75%). No patient with U-MRD by NGS in BM or PBMC was MRD+ in plasma. Patients with mutated IGHV were more likely to have U-MRD by NGS at the end of treatment (EOT; 41% vs 13%, P = .02) than those with unmutated IGHV. Median follow-up was 81.6 months. Patients with U-MRD at EOT had superior PFS vs MRD+ patients, regardless of sample type assessed (BM, P = .02, median not reached [NR] vs 67 months; PBMC, P = .02, median NR vs 74 months). More sensitive MRD6 testing increases prognostic discrimination over MRD4 testing.
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Abstract
PURPOSE OF REVIEW Chronic lymphocytic leukaemia is now recognised as a heterogenous disease with a variety of clinical outcomes. Here we summarise the way it is currently stratified according to genetic risk and patient characteristics and the treatment approaches used for these different subgroups. RECENT FINDINGS Certain patients appear to sustain MRD negativity after combination chemoimmunotherapy, leading to the suggestion that their CLL may be cured. However, 17p-deleted, p53-mutated or IGHV-UM subgroups are generally resistant to FCR, and much better responses are seen with ibrutinib and venetoclax, frequently inducing MRD negativity that hopefully will be translated into durable remissions. Small molecule inhibitors have already revolutionised CLL treatment. Going forward, we anticipate their use in the majority of patients, early after diagnosis and with curative intent.
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Affiliation(s)
- Kate Milne
- Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PS UK
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE UK
| | - Beattie Sturrock
- Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PS UK
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE UK
| | - Timothy Chevassut
- Brighton and Sussex Medical School, University of Sussex, Brighton, BN1 9PS UK
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE UK
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Hus I, Salomon-Perzyński A, Robak T. The up-to-date role of biologics for the treatment of chronic lymphocytic leukemia. Expert Opin Biol Ther 2020; 20:799-812. [DOI: 10.1080/14712598.2020.1734557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Iwona Hus
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz and Copernicus Memorial Hospital, Lodz, Poland
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Bosch F, Cantin G, Cortelezzi A, Knauf W, Tiab M, Turgut M, Zaritskey A, Merot JL, Tausch E, Trunzer K, Robson S, Gresko E, Böttcher S, Foà R, Stilgenbauer S, Leblond V. Obinutuzumab plus fludarabine and cyclophosphamide in previously untreated, fit patients with chronic lymphocytic leukemia: a subgroup analysis of the GREEN study. Leukemia 2020; 34:441-450. [PMID: 31455851 PMCID: PMC7214269 DOI: 10.1038/s41375-019-0554-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 12/21/2022]
Abstract
GREEN (NCT01905943) is a nonrandomized, open-label, single-arm, phase 3b study investigating the safety and efficacy of obinutuzumab alone or in combination with chemotherapy in chronic lymphocytic leukemia (CLL). We report the preplanned subgroup analysis of 140 previously untreated, fit CLL patients who received obinutuzumab plus fludarabine and cyclophosphamide (G-FC). The primary endpoint was safety and tolerability. Efficacy was the secondary endpoint. Obinutuzumab 1000 mg was administered intravenously on Day (D)1 (dose split D1‒2), D8 and D15 of Cycle (C)1, and D1 of C2-6 (28-day cycles). Standard intravenous/oral doses of fludarabine and cyclophosphamide were administered on D1-3 of C1-6. Overall, 87.1% of patients experienced grade ≥ 3 adverse events (AEs), including neutropenia (67.1%) and thrombocytopenia (17.1%). Serious AEs were experienced by 42.1% of patients. Rates of grade ≥ 3 infusion-related reactions and infections were 19.3% and 15.7%, respectively. Overall response rate was observed in 90.0%, with 46.4% of patients achieving complete response (CR; including CR with incomplete marrow recovery). Minimal residual disease negativity rates were 64.3% in peripheral blood and 35.7% in bone marrow (intent-to-treat analysis). After a median observation time of 25.6 months, 2 year progression-free survival was 91%. Frontline G-FC represents a promising treatment option for fit patients with CLL.
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Affiliation(s)
| | - Guy Cantin
- Hopital De L'Enfant-Jesus, Quebec City, QC, Canada
| | | | - Wolfgang Knauf
- Onkologische Gemeinschaftspraxis, Agaplesion Bethanien Krankenhaus, Frankfurt, Germany
| | - Mourad Tiab
- University Hospital, La Roche Sur Yon, France
| | | | | | | | - Eugen Tausch
- Department of Internal Medicine III, Ulm University, Ulm and Innere Medizin I, Universitätsklinikum des Saarlandes, Homburg, Germany
| | | | | | | | - Sebastian Böttcher
- Second Department of Medicine, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany and Clinic III, Hematology, Oncology and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Robin Foà
- Hematology, Sapienza University, Rome, Italy
| | - Stephan Stilgenbauer
- Department of Internal Medicine III, Ulm University, Ulm and Innere Medizin I, Universitätsklinikum des Saarlandes, Homburg, Germany
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Khan Y, Lyou Y, El-Masry M, O’Brien S. Reassessing the role of chemoimmunotherapy in chronic lymphocytic leukemia. Expert Rev Hematol 2019; 13:31-38. [DOI: 10.1080/17474086.2020.1697226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Yasir Khan
- Division of Hematology and Oncology, University of California Irvine, Irvine, CA, USA
| | - Yung Lyou
- Department of Medical Oncology and Experimental Therapeutics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Monica El-Masry
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Susan O’Brien
- Division of Hematology and Oncology, University of California Irvine, Irvine, CA, USA
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Wake LM, Ahn IE, Farooqui MZ, Tian X, Stetler-Stevenson M, Marti GE, Wiestner A, Maric I. Dual antibody immunohistochemistry: an efficient and sensitive tool for the detection of residual disease in chronic lymphocytic leukemia. J Hematop 2019. [DOI: 10.1007/s12308-019-00372-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Fürstenau M, De Silva N, Eichhorst B, Hallek M. Minimal Residual Disease Assessment in CLL: Ready for Use in Clinical Routine? Hemasphere 2019; 3:e287. [PMID: 31942542 PMCID: PMC6919470 DOI: 10.1097/hs9.0000000000000287] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022] Open
Abstract
The introduction of chemoimmunotherapy and more recently the implementation of novel agents into first-line and relapse treatment have substantially improved treatment outcomes in patients with chronic lymphocytic leukaemia (CLL). With longer progression-free survival and more frequently observed deep remissions there is an emerging need for sensitive methods quantitating residual disease after therapy. Over the last decade, assessment of minimal residual disease (MRD) has increasingly been implemented in CLL trials. The predictive value of MRD status on survival outcomes has repeatedly been proven in the context of chemoimmunotherapy and cellular therapies. Recent data suggests a similar correlation for Bcl-2 inhibitor-based therapy. While the relevance of MRD assessment as a surrogate endpoint in clinical trials is largely undisputed, its role in routine clinical practice has not yet been well defined. This review outlines current methods of MRD detection in CLL and summarizes MRD data from relevant trials. The significance of MRD testing in clinical studies and in routine patient care is assessed and new MRD-guided treatment strategies are discussed.
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Affiliation(s)
- Moritz Fürstenau
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Nisha De Silva
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Bonn Cologne Düsseldorf, German CLL Study Group, University Hospital Cologne, Cologne, Germany
- Cologne Cluster of Excellence in Cellular Stress Responses in Aging-associated Disease (CECAD), University of Cologne, Cologne, Germany
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Del Giudice I, Raponi S, Della Starza I, De Propris MS, Cavalli M, De Novi LA, Cappelli LV, Ilari C, Cafforio L, Guarini A, Foà R. Minimal Residual Disease in Chronic Lymphocytic Leukemia: A New Goal? Front Oncol 2019; 9:689. [PMID: 31555576 PMCID: PMC6727319 DOI: 10.3389/fonc.2019.00689] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/12/2019] [Indexed: 12/18/2022] Open
Abstract
In chronic lymphocytic leukemia (CLL), there is a growing interest for minimal residual disease (MRD) monitoring, due to the availability of drug combinations capable of unprecedented complete clinical responses. The standardized and most commonly applied methods to assess MRD in CLL are based on flow cytometry (FCM) and, to a lesser extent, real-time quantitative PCR (RQ-PCR) with allele-specific oligonucleotide (ASO) primers of immunoglobulin heavy chain genes (IgH). Promising results are being obtained using droplet digital PCR (ddPCR) and next generation sequencing (NGS)-based approaches, with some advantages and a potential higher sensitivity compared to the standardized methodologies. Plasma cell-free DNA can also be explored as a more precise measure of residual disease from all different compartments, including the lymph nodes. From a clinical point of view, CLL MRD quantification has proven an independent prognostic marker of progression-free survival (PFS) and overall survival (OS) after chemoimmunotherapy as well as after allogeneic transplantation. In the era of mechanism-driven drugs, the paradigms of CLL treatment are being revolutionized, challenging the use of chemoimmunotherapy even in first-line. The continuous administration of ibrutinib single agent has led to prolonged PFS and OS in relapsed/refractory and treatment naïve CLL, including those with TP53 deletion/mutation or unmutated IGHV genes, though the clinical responses are rarely complete. More recently, chemo-free combinations of venetoclax+rituximab, venetoclax+obinutuzumab or ibrutinib+venetoclax have been shown capable of inducing undetectable MRD in the bone marrow, opening the way to protocols exploring a MRD-based duration of treatment, aiming at disease eradication. Thus, beside a durable disease control desirable particularly for older patients and/or for those with comorbidities, a MRD-negative complete remission is becoming a realistic prospect for CLL patients in an attempt to obtain a long-lasting eradication and possibly cure of the disease. Here we discuss the standardized and innovative technical approaches for MRD detection in CLL, the clinical impact of MRD monitoring in chemoimmunotherapy and chemo-free trials and the future clinical implications of MRD monitoring in CLL patients outside of clinical trials.
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Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Sara Raponi
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Irene Della Starza
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.,GIMEMA Foundation, Rome, Italy
| | - Maria Stefania De Propris
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marzia Cavalli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucia Anna De Novi
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luca Vincenzo Cappelli
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Caterina Ilari
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luciana Cafforio
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Anna Guarini
- Department of Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Madu AJ, Korubo K, Okoye A, Ajuba I, Duru AN, Ugwu AO, Nnachi O, Okoye HC. Presenting features and treatment outcomes of chronic lymphocytic leukaemia in a resource poor Southern Nigeria. Malawi Med J 2019; 31:144-149. [PMID: 31452848 PMCID: PMC6698622 DOI: 10.4314/mmj.v31i2.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background Chronic lymphocytic leukaemia is a relatively common haematological malignancy affecting older adults, accounting for about 20% of haematological malignancies in Nigeria. Diagnosis of this disease depends on the demonstration of clonal lymphocytosis > 5 × 109/L with a characteristic immunophenotypic pattern amidst other clinical and laboratory features. Objectives To determine the predominant clinical and laboratory features of CLL at presentation and their relationship with patient survival. This study also aims at examining the relationship between treatment protocol and outcome. Methods This is a retrospective study with 8 years data (2010–2018) collected from four different centers. Data was analyzed using SPSS 20.0. Results There were a total of 97 cases, with a male: female ratio of 1.1:1. The median age at presentation was 59 years. Approximately 55% of the patients presented at Binet stage C, with splenomegaly in 93.2% and 78% were anaemic. The mean white cell count was 137.9 ± 14.7 × 109/L, with a median absolute lymphocyte count of 86 × 109/L. The commonest treatment regimen was chlorambucil and prednisolone and males had a superior response. The number of chemotherapy cycles, serum alkaline phosphatase and aspartate transaminase correlated positively with duration of survival. Mortality rate over the five year period was 14.3%. Conclusion CLL was found to present in younger patients when compared to previous studies with a median age of 57 years at diagnosis. Our study showed a slight female preponderance and better response to therapy in males. Majority of the patients presented in Binet stage C and were treated with chlorambucil-based drug combinations compared to more current treatment with Fludarabine-based combinations. A high serum alanine transaminase and alkaline phosphatase was found to positively correlate with survival amongst this patient population
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Affiliation(s)
- Anazoeze Jude Madu
- Department of Haematology and Immunology, University of Nigeria Enugu Campus
| | | | - Augustine Okoye
- Department of Haematology, Federal Teaching Hospital Abakaliki
| | - Ifeoma Ajuba
- Department of Haematology Nnamdi Azikiwe University, Nnewi, Anambra State
| | - Augustine N Duru
- Department of Haematology and Immunology, University of Nigeria Enugu Campus
| | - Angela O Ugwu
- Department of Haematology and Immunology, University of Nigeria Enugu Campus
| | - Oji Nnachi
- Department of Haematology, Federal Teaching Hospital Abakaliki
| | - Helen Chioma Okoye
- Department of Haematology and Immunology, University of Nigeria Enugu Campus
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48
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Gauthier M, Durrieu F, Martin E, Peres M, Vergez F, Filleron T, Obéric L, Bijou F, Quillet Mary A, Ysebaert L. Prognostic role of CD4 T-cell depletion after frontline fludarabine, cyclophosphamide and rituximab in chronic lymphocytic leukaemia. BMC Cancer 2019; 19:809. [PMID: 31412798 PMCID: PMC6694602 DOI: 10.1186/s12885-019-5971-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 07/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Eradication of minimal residual disease (MRD), at the end of Fludarabine-Cyclophosphamide-Rituximab (FCR) treatment, is a validated surrogate marker for progression-free and overall survival in chronic lymphocytic leukaemia. But such deep responses are also associated with severe immuno-depletion, leading to infections and the development of secondary cancers. METHODS We assessed, blood MRD and normal immune cell levels at the end of treatment, in 162 first-line FCR patients, and analysed survival and adverse event. RESULTS Multivariate Landmark analysis 3 months after FCR completion identified unmutated IGHV status (HR, 2.03, p = 0.043), the level of MRD reached (intermediate versus low, HR, 2.43, p = 0.002; high versus low, HR, 4.56, p = 0.002) and CD4 > 200/mm3 (HR, 3.30, p < 0.001) as factors independently associated with progression-free survival (PFS); neither CD8 nor NK counts were associated with PFS. The CD4 count was associated with PFS irrespective of IGHV mutational status, but only in patients with detectable MRD (HR, 3.51, p = 0.0004, whereas it had no prognostic impact in MRD < 10- 4 patients: p = 0.6998). We next used a competitive risk model to investigate whether immune cell subsets could be associated with the risk of infection and found no association between CD4, CD8 and NK cells and infection. CONCLUSIONS Consolidation/maintenance trials based on detectable MRD after FCR should investigate CD4 T-cell numbers both as a selection and a response criterion, and consolidation treatments should target B-cell/T-cell interactions.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- CD4-Positive T-Lymphocytes/drug effects
- CD4-Positive T-Lymphocytes/pathology
- Cyclophosphamide/adverse effects
- Cyclophosphamide/therapeutic use
- Female
- Follow-Up Studies
- Humans
- Immunoglobulin Variable Region/genetics
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphocyte Count
- Male
- Middle Aged
- Mutation
- Neoplasm, Residual
- Prognosis
- Rituximab/adverse effects
- Rituximab/therapeutic use
- Survival Analysis
- Treatment Outcome
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
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Affiliation(s)
- Martin Gauthier
- Department of Haematology, Toulouse-Oncopole University Cancer Institute (IUCT-O), 1 Avenue Irene Joliot-Curie, 31059, Toulouse, France
| | - Françoise Durrieu
- Department of Biology Haematology, Institut Bergonié, Bordeaux, France
| | - Elodie Martin
- Department of Biostatistics, Institut Claudius Regaud, IU, CT-O, Toulouse, France
| | - Michael Peres
- Department of Biology Haematology, Toulouse-Oncopole University Cancer Institute (IUCT-O), Toulouse, France
| | - François Vergez
- Department of Biology Haematology, Toulouse-Oncopole University Cancer Institute (IUCT-O), Toulouse, France
| | - Thomas Filleron
- Department of Biostatistics, Institut Claudius Regaud, IU, CT-O, Toulouse, France
| | - Lucie Obéric
- Department of Haematology, Toulouse-Oncopole University Cancer Institute (IUCT-O), 1 Avenue Irene Joliot-Curie, 31059, Toulouse, France
| | - Fontanet Bijou
- Department of Medical Haematology, Institut Bergonié, Bordeaux, France
| | - Anne Quillet Mary
- Inserm UMR1037, Cancer Research Centre of Toulouse, Toulouse, France
| | - Loic Ysebaert
- Department of Haematology, Toulouse-Oncopole University Cancer Institute (IUCT-O), 1 Avenue Irene Joliot-Curie, 31059, Toulouse, France.
- Inserm UMR1037, Cancer Research Centre of Toulouse, Toulouse, France.
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Davids MS, Brander DM, Kim HT, Tyekucheva S, Bsat J, Savell A, Hellman JM, Bazemore J, Francoeur K, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng S, Crombie J, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Fisher DC, Brown JR. Ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial treatment for younger patients with chronic lymphocytic leukaemia: a single-arm, multicentre, phase 2 trial. Lancet Haematol 2019; 6:e419-e428. [PMID: 31208944 PMCID: PMC7036668 DOI: 10.1016/s2352-3026(19)30104-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 05/28/2019] [Accepted: 05/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fludarabine, cyclophosphamide, and rituximab (FCR) can improve disease-free survival for younger (age ≤65 years) fit patients with chronic lymphocytic leukaemia with mutated IGHV. However, patients with unmutated IGHV rarely have durable responses. Ibrutinib is active for patients with chronic lymphocytic leukaemia irrespective of IGHV mutation status but requires continuous treatment. We postulated that time-limited ibrutinib plus FCR would induce durable responses in younger fit patients with chronic lymphocytic leukaemia. METHODS We did a multicentre, open-label, non-randomised, single-arm phase 2 trial at seven sites in the USA. We enrolled patients aged 65 years or younger with previously untreated chronic lymphocytic leukaemia. Our initial cohort (original cohort) was not restricted by prognostic marker status and included patients who had del(17p) or TP53 aberrations. After a protocol amendment (on March 21, 2017), we enrolled an additional cohort (expansion cohort) that included patients without del(17p). Ibrutinib was given orally (420 mg/day) for 7 days, then up to six 28-day cycles were administered intravenously of fludarabine (25 mg/m2, days 1-3), cyclophosphamide (250 mg/m2, days 1-3), and rituximab (375 mg/m2 day 1 of cycle 1; 500 mg/m2 day 1 of cycles 2-6) with continuous oral ibrutinib (420 mg/day). Responders continued on ibrutinib maintenance for up to 2 years, and patients with undetectable minimal residual disease in bone marrow after 2 years were able to discontinue treatment. The primary endpoint was the proportion of patients who achieved a complete response with undetectable minimal residual disease in bone marrow 2 months after the last cycle of ibrutinib plus FCR. Analyses were done per-protocol in all patients who received at least one dose of study treatment. This trial is registered with ClinicalTrials.gov (NCT02251548) and is ongoing. FINDINGS Between Oct 23, 2014, and April 23, 2018, 85 patients with chronic lymphocytic leukaemia were enrolled. del(17p) was detected in four (5%) of 83 patients and TP53 mutations were noted in three (4%) of 81 patients; two patients had both del(17p) and TP53 mutations. Median patients' age was 55 years (IQR 50-58). At data cutoff, median follow-up was 16·5 months (IQR 10·6-34·1). A complete response and undetectable minimal residual disease in bone marrow 2 months after the last cycle of ibrutinib plus FCR was achieved by 28 (33%, 95% CI 0·23-0·44) of 85 patients (p=0·0035 compared with a 20% historical value with FCR alone). A best response of undetectable minimal residual disease in bone marrow was achieved by 71 (84%) of 85 patients during the study. One patient had disease progression and one patient died (sudden cardiac death after 17 months of ibrutinib maintenance, assessed as possibly related to ibrutinib). The most common all-grade toxic effects were haematological, including thrombocytopenia in 63 (74%) patients, neutropenia in 53 (62%), and anaemia in 41 (49%). Grade 3 or 4 non-haematological serious adverse events included grade 3 atrial fibrillation in three (4%) patients and grade 3 Pneumocystis jirovecii pneumonia in two (2%). INTERPRETATION The proportion of patients who achieved undetectable minimal residual disease in bone marrow with ibrutinib plus FCR is, to our knowledge, the highest ever published in patients with chronic lymphocytic leukaemia unrestricted by prognostic marker status. Ibrutinib plus FCR is promising as a time-limited combination regimen for frontline chronic lymphocytic leukaemia treatment in younger fit patients. FUNDING Pharmacyclics and the Leukemia & Lymphoma Society.
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Affiliation(s)
- Matthew S Davids
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA.
| | | | - Haesook T Kim
- Dana-Farber Cancer Institute, Department of Data Sciences, Harvard T H Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Svitlana Tyekucheva
- Dana-Farber Cancer Institute, Department of Data Sciences, Harvard T H Chan School of Public Health, Department of Biostatistics, Boston, MA, USA
| | - Jad Bsat
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Alexandra Savell
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jeffrey M Hellman
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Josie Bazemore
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Karen Francoeur
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Alvaro Alencar
- University of Miami Sylvester Comprehensive Cancer Center, Department of Hematology and Oncology, Miami, FL, USA
| | - Leyla Shune
- University of Kansas Cancer Center, Department of Hematologic Malignancies, Westwood, KS, USA
| | - Mohammad Omaira
- West Michigan Cancer Center, Department of Medical Oncology, Kalamazoo, MI, USA
| | - Caron A Jacobson
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Philippe Armand
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Samuel Ng
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jennifer Crombie
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Ann S LaCasce
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jon Arnason
- Beth Israel Deaconess Medical Center, Department of Medical Oncology, Boston, MA, USA
| | - Ephraim P Hochberg
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - Ronald W Takvorian
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - Jeremy S Abramson
- Massachusetts General Hospital, Department of Medical Oncology, Boston, MA, USA
| | - David C Fisher
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Department of Medical Oncology, Boston, MA, USA
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50
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Michallet AS, Dilhuydy MS, Subtil F, Rouille V, Mahe B, Laribi K, Villemagne B, Salles G, Tournilhac O, Delmer A, Portois C, Pegourie B, Leblond V, Tomowiak C, de Guibert S, Orsini F, Banos A, Carassou P, Cartron G, Fornecker LM, Ysebaert L, Dartigeas C, Truchan Graczyk M, Vilque JP, Aurran T, Cymbalista F, Lepretre S, Lévy V, Nguyen-Khac F, Le Garff-Tavernier M, Aanei C, Ticchioni M, Letestu R, Feugier P. Obinutuzumab and ibrutinib induction therapy followed by a minimal residual disease-driven strategy in patients with chronic lymphocytic leukaemia (ICLL07 FILO): a single-arm, multicentre, phase 2 trial. LANCET HAEMATOLOGY 2019; 6:e470-e479. [PMID: 31324600 DOI: 10.1016/s2352-3026(19)30113-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/17/2019] [Accepted: 05/24/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND In patients with chronic lymphocytic leukaemia, achievement of a complete response with minimal residual disease of less than 0·01% (ie, <1 chronic lymphocytic leukaemia cell per 10 000 leukocytes) in bone marrow has been associated with improved progression-free survival. We aimed to explore the activity of induction therapy for 9 months with obinutuzumab and ibrutinib, followed up with a minimal residual disease-driven therapeutic strategy for 6 additional months, in previously untreated patients. METHODS We did a single-arm, phase 2 trial in 27 university hospitals, general hospitals, and specialist cancer centres in France. Eligible patients were at least 18 years old and previously untreated, and had immunophenotypically confirmed B-cell chronic lymphocytic leukaemia; an Eastern Cooperative Oncology Group (ECOG) performance status score of less than 2; a Binet stage C according to IWCLL 2008 criteria or Binet stage A and B with active disease; no 17p deletion or absence of p53 mutation; and were considered medically fit. In the first part of the study (induction phase), all participants received eight intravenous infusions of obinutuzumab 1000 mg over six 4-weekly cycles and oral ibrutinib 420 mg once per day for 9 months. In part 2, after assessment on day 1 of month 9, patients with a complete response and bone marrow minimal residual disease of less than 0·01% received only oral ibrutinib 420 mg once per day for 6 additional months. Patients with a partial response, or with a complete response and bone marrow minimal residual disease of 0·01% or more, received 6 months of four 4-weekly cycles of intravenous fludarabine, cyclophosphamide, and obinutuzumab 1000 mg, alongside continuing ibrutinib 420 mg once per day. The primary endpoint was the proportion of patients achieving a complete response with bone marrow minimal residual disease less than 0·01% on day 1 of month 16 assessed by intention to treat (ITT). This trial is registered with ClinicalTrials.gov (number NCT02666898) and is still open for follow-up. FINDINGS Between Oct 27, 2015, and May 16, 2017, 135 patients were enrolled. After induction treatment (day 1 of month 9), 130 patients were evaluable, of which ten (8%) achieved a complete response with bone marrow minimal residual disease of less than 0·01% and were assigned to ibrutinib, and 120 (92%) were assigned to ibrutinib plus fludarabine, cyclophosphamide, and obinutuzumab. After minimal residual disease-guided treatment (day 1 of month 16), 84 (62%, 90% CI 55-69) of 135 patients (ITT population) achieved a complete response with bone marrow minimal residual disease of less than 0·01%. The most common haematological adverse event was thrombocytopenia (in 45 [34%] of 133 patients at grade 1-2 in months 1-9 and in 43 [33%] of 130 patients at grade 1-2 in months 9-15). The most common non-haematological adverse events were infusion-related reactions (in 83 [62%] patients at grade 1-2 in months 1-9) and gastrointestinal disorders (in 62 [48%] patients at grades 1 and 2 in months 9-15). 49 serious adverse events occurred, most frequently infections (ten), cardiac events (eight), and haematological events (eight). No treatment-related deaths occurred. INTERPRETATION Obinutuzumab and ibrutinib induction therapy followed by a minimal residual disease driven strategy is safe and active in patients with previously untreated chronic lymphocytic leukaemia. With longer follow-up, including assessing the evolution of minimal residual disease, if response is maintained, this strategy could be an option in the first-line setting in patients with chronic lymphocytic leukaemia, although randomised evidence is needed. FUNDING Roche, Janssen.
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MESH Headings
- Adenine/analogs & derivatives
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Drug Administration Schedule
- Female
- Gastrointestinal Diseases/etiology
- Humans
- Immunoglobulin Heavy Chains/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Mutation
- Neoplasm, Residual
- Piperidines
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Survival Rate
- Thrombocytopenia/etiology
- Treatment Outcome
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
| | | | - Fabien Subtil
- Department of Biostatistics, Hospices Civils de Lyon, Lyon, France
| | - Valerie Rouille
- Department of Hematology, CHU Montpellier, Montpellier, France
| | - Beatrice Mahe
- Department of Hematology, CHU Nantes, Nantes, France
| | - Kamel Laribi
- Department of Clinical Hematology, Centre Hospitalier du Mans, Le Mans, France
| | - Bruno Villemagne
- Department of Clinical Hematology, CHD Vendee, La Roche sur Yon, France
| | - Gilles Salles
- Department of Hematology, Hospices Civils de Lyon, Lyon, France
| | - Olivier Tournilhac
- Department of Hematology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Alain Delmer
- Department of Hematology, CHU Reims, Reims, France
| | | | | | - Veronique Leblond
- Department of Hematology, Assistance Publique Hopitaux de Paris, PitiéSalpêtrière Hospital, Université Paris Sorbonne, Paris, France
| | | | | | - Frederique Orsini
- Department of Clinical Hematology, Centre Hospitalier Annecy Genevois, Annecy Genevois, France
| | - Anne Banos
- Department of Clinical Hematology, Centre Hospitalier Bayonne, Bayonne, France
| | | | | | | | - Loic Ysebaert
- Department of Hematology, CHU Toulouse, Toulouse, France
| | | | | | | | - Thérèse Aurran
- Department of Hematology, Institut Paoli Calmettes, Marseille, Marseille, France
| | - Florence Cymbalista
- Department of Hematology, Avicenne Hospital, Assistance Publique Hopitaux de Paris, Bobigny, France
| | - Stéphane Lepretre
- Department of Hematology, Centres de Lutte Contre le Cancer Centre Henri-Becquerel, Haute Normandie, Rouen, France
| | - Vincent Lévy
- URC/CRC, Avicenne Hospital, Assistance Publique Hopitaux de Paris, Bobigny, France
| | - Florence Nguyen-Khac
- Department of Hematology, Assistance Publique Hopitaux de Paris, PitiéSalpêtrière Hospital, Université Paris Sorbonne, Paris, France
| | - Magali Le Garff-Tavernier
- Department of Hematology Biology, Assistance Publique Hopitaux de Paris, Pitié Salpêtrière, Paris, France
| | - Carmen Aanei
- Department of Hematology Biology, CHU Saint Etienne, Saint Etienne, France
| | | | - Rémi Letestu
- Department of Hematology Biology, Avicenne Hospital, Assistance Publique Hopitaux de Paris, Bobigny, France
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