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Abstract
PURPOSE OF REVIEW There have been significant advances in the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL) over the past two decades. However, the intention of treatment remains control of the disease and delay of progression rather than a cure which remains largely elusive. Considering that CLL is mostly seen in older patients, there are multiple factors that play a role in the selection of CLL beyond the frontline treatment. Here, we review the concept of relapsed CLL, factors that predispose to relapse, and therapeutic options available to this patient population. We also review investigational therapies and provide a framework for selection of therapies in this setting. RECENT FINDINGS Targeted therapies with continuous BTK inhibitors (BTKi) or fixed duration venetoclax plus anti-CD20 monoclonal antibody therapy have established superiority over chemoimmunotherapy in relapsed CLL and have become the preferred standard of care treatment. The second-generation more selective BTK inhibitors (acalabrutinib and zanubrutinib) have shown improved safety profile compared to ibrutinib. However, resistance to the covalent BTK inhibitors may emerge and is commonly associated with mutations in BTK or other downstream enzymes. The novel non-covalent BTK inhibitors such as pirtobrutinib (Loxo-305) and nemtabrutinib (ARQ 531) are showing promising activities for relapsed CLL refractory to prior covalent BTKi. Other novel therapies such as chimeric antigen receptor (CAR) T cell therapy have also shown significant activities for relapsed and refractory CLL. Measurable residual disease (MRD) assessment has a growing importance in venetoclax-based limited-duration therapy and there is mounting evidence that MRD negativity improves outcomes. However, it remains to be seen if this will become an established clinically significant endpoint. Further, the optimal sequence of various treatment options remains to be determined. Patients with relapsed CLL now have more options for the treatment of the disease. The choice of therapy is best individualized especially in the absence of direct comparisons of targeted therapies, and the coming years will bring more data on the best sequence of use of the therapeutic agents.
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Affiliation(s)
- Oluwatobi Odetola
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA.
| | - Shuo Ma
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA
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Nguyen TT, Nhu NT, Tran VK, Viet-Nhi NK, Ho XD, Jhan MK, Chen YP, Lin CF. Efficacy and safety of add-on anti-CD20 monoclonal antibody to Bruton tyrosine kinase inhibitor treatment for chronic lymphocytic leukemia: a meta-analysis. Sci Rep 2023; 13:9775. [PMID: 37328530 PMCID: PMC10276018 DOI: 10.1038/s41598-023-36279-x] [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: 01/10/2023] [Accepted: 05/31/2023] [Indexed: 06/18/2023] Open
Abstract
The efficacy of Bruton tyrosine kinase inhibitors (BTKi) remains suboptimal in chronic lymphocytic leukemia (CLL) treatment. A systematic review and meta-analysis were conducted to compare the outcomes of combining anti-CD20 monoclonal antibodies (mAb) with BTKi therapy versus BTKi monotherapy for patients with CLL. We searched for relevant studies in the Pubmed, Medline, Embase, and Cochrane databases until December 2022. We estimated the effective results using a hazard ratio (HR) for survival outcomes and relative risk (RR) for response outcomes and safety. Four randomized controlled trials (including 1056 patients) were found until November 2022 and fulfilled the inclusion criteria. Progression-free survival was significantly improved with the addition of anti-CD20 mAb to BTKi over BTKi (HR 0.70, 95% confidence interval (CI) 0.51-0.97), whereas pooled analysis of overall survival did not favor combination therapy compared to BTKi monotherapy (HR 0.72, 95% CI 0.50-1.04). Combination therapy was related to a statistically better complete response (RR, 2.03; 95% CI 1.01 to 4.06) and an undetectable minimal residual disease rate (RR, 6.43; 95% CI 3.54 to 11.67). The risk of grade ≥ 3 adverse events was comparable between the two groups (RR, 1.08; (95% CI 0.80 to 1.45). Overall, adding anti-CD20 mAb to BTKi revealed superior efficacy than BTKi alone in untreated or previously treated CLL patients without affecting the safety of single-agent BTKi. Conducting further randomized studies to confirm our results and determine the optimal therapy for managing patients with CLL is essential.
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Affiliation(s)
- Thi Thuy Nguyen
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Department of Oncology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Nguyen Thanh Nhu
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Van Khoi Tran
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
- Department of Surgery, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Nguyen-Kieu Viet-Nhi
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Xuan Dung Ho
- Department of Oncology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Ming-Kai Jhan
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, No. 25, Wuxing St, Xinyi District, Taipei, 110, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan
| | - Ya-Ping Chen
- Division of Hematology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 704, Taiwan
| | - Chiou-Feng Lin
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, No. 25, Wuxing St, Xinyi District, Taipei, 110, Taiwan.
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan.
- Core Laboratory of Immune Monitoring, Office of Research & Development, Taipei Medical University, Taipei, 110, Taiwan.
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Front-line fludarabine-cyclophosphamide-rituximab (FCR) in 110 patients with chronic lymphocytic leukaemia (CLL): real-life experience with long-term outcomes, toxicities and responses to second-line therapies. Int J Hematol 2023; 117:388-397. [PMID: 36449134 DOI: 10.1007/s12185-022-03488-5] [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: 06/16/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022]
Abstract
Fludarabine-cyclophosphamide-rituximab (FCR) has been the gold standard front-line treatment for fit CLL patients until novel agent's introduction. Decision between either time-limited FCR or "endless" Bruton's tyrosine kinase inhibitor (BTKi) therapy may be difficult in fit IGHV-mutated-non-TP53 cases. We describe the outcomes after front-line FCR in 110 CLL patients from 5 centres in Catalonia, Spain, over a period of more than 10 years. ORR was 96.3% and CR 74.5%. Median second-treatment free survival (TFS1) was 6.2 years and median OS was 10.8 years. 50 (45.5%) patients required a subsequent therapy. Median third-treatment free survival was better for BTKi than for chemotherapy ± antiCD20 strategies (not reached vs 3.1 years, p = 0.003). Only 50 (45.5%) patients completed 6 cycles of FCR, and the main reason for discontinuation was cytopenia 29 (26.4%). 15 (13.6%) patients developed a second cancer, and 5 (4.5%) patients experienced a Richter's transformation (RT). At the end of follow-up, 50 (45.5%) patients remained in CR. Response rates, TFS1, OS, RT, and second cancers did not differ between patients treated with 6 vs 4 cycles of FCR. In conclusion, front-line FCR treatment leads to very long CR in almost half of patients, and BTKi yields excellent outcomes in relapsed patients.
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Munir T, Emmerson J, Hockaday A, Oughton JB, Howard D, Phillips D, Neilson J, Pemberton N, Paneesha S, Kennedy B, Rawstron A, Hillmen P. Obinutuzumab as consolidation after chemo-immunotherapy: Results of the UK National Cancer Research Institute phase II/III GALACTIC trial. Br J Haematol 2022; 199:707-719. [PMID: 36017875 DOI: 10.1111/bjh.18427] [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: 04/30/2022] [Revised: 08/04/2022] [Accepted: 08/12/2022] [Indexed: 01/07/2023]
Abstract
The GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In chronic lymphocytic leukaemia (CLL) (GALACTIC) was a seamless phase II/III trial designed to test whether consolidation with obinutuzumab is safe and eradicates minimal residual disease (MRD) and, subsequently, whether this leads to prolonged progression-free survival (PFS) in patients with CLL who have recently responded to chemo-immunotherapy. Patients with a response 3-24 months after chemotherapy were assessed for MRD. MRD-positive patients were randomised to receive consolidation therapy with obinutuzumab or no consolidation. The trial closed after the phase II part due to slow recruitment. In all, 48 patients enrolled of whom 19 were MRD negative and were monitored. Of the 29 MRD-positive patients, 14 were randomised to receive consolidation and 15 to no consolidation. At 6 months after randomisation, 10 and 13 consolidated patients achieved MRD negativity by flow cytometry (sensitivity 10-4 ) in bone marrow and peripheral blood respectively. PFS was significantly better in consolidated patients compared to non-consolidated patients (p = 0.001). No difference was observed in PFS, overall survival or duration of MRD negativity when comparing the 10 MRD-negative patients after consolidation with the 19 MRD-negative patients in the monitoring group. Common adverse events in the consolidation arm were thrombocytopenia, infection, and cough. Only 1% of events were infusion-related reactions. This observation provides further evidence that consolidation to achieve MRD negativity improves outcomes in CLL and that obinutuzumab is well tolerated in patients with low levels of disease.
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Affiliation(s)
- Talha Munir
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Jake Emmerson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie B Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Dena Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | | | | | - Andy Rawstron
- Haematological Malignancy Diagnostic Service, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Peter Hillmen
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
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Overcoming resistance hurdles. Blood 2022; 139:804-805. [PMID: 35142854 DOI: 10.1182/blood.2021014430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
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Is BTKi or BCL2i preferable as first novel therapy in patients with CLL? The case for BCL2i. Blood Adv 2021; 6:1365-1370. [PMID: 34965297 PMCID: PMC8864649 DOI: 10.1182/bloodadvances.2019001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abrisqueta P, Loscertales J, Terol MJ, Ramírez Payer Á, Ortiz M, Pérez I, Cuellar-García C, Fernández de la Mata M, Rodríguez A, Lario A, Delgado J, Godoy A, Arguiñano Pérez JM, Berruezo MJ, Oliveira A, Hernández-Rivas JÁ, García Malo MD, Medina Á, García Martin P, Osorio S, Baltasar P, Fernández-Zarzoso M, Marco F, Vidal Manceñido MJ, Smucler Simonovich A, López Rubio M, Jarque I, Suarez A, Fernández Álvarez R, Lancharro Anchel A, Ríos E, Losada Castillo MDC, Pérez Persona E, García Muñoz R, Ramos R, Yáñez L, Bello JL, Loriente C, Acha D, Villanueva M. Real-World Characteristics and Outcome of Patients Treated With Single-Agent Ibrutinib for Chronic Lymphocytic Leukemia in Spain (IBRORS-LLC Study). CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e985-e999. [PMID: 34511320 DOI: 10.1016/j.clml.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Ibrutinib demonstrated remarkable efficacy and favorable tolerability in patients with untreated or relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL), including those with high-risk genetic alterations. The IBRORS-CLL study assessed the characteristics, clinical management and outcome of CLL patients receiving ibrutinib in routine clinical practice in Spain. PATIENTS Observational, retrospective, multicenter study in CLL patients who started single-agent ibrutinib as first-line treatment or at first or second relapse between January 2016 and January 2019. RESULTS A total of 269 patients were included (median age: 70.9 years; cardiovascular comorbidity: 55.4%, including hypertension [47.6%] and atrial fibrillation [AF] [7.1%]). Overall, 96.7% and 69% of patients underwent molecular testing for del(17p)/TP53 mutation and IGHV mutation status. High-risk genetic features included unmutated IGHV (79%) and del(17p)/TP53 mutation (first-line: 66.3%; second-line: 23.1%). Overall, 84 (31.2%) patients received ibrutinib as first-line treatment, and it was used as second- and third-line therapy in 121 (45.0%) and 64 (23.8%) patients. The median progression-free survival and overall survival were not reached irrespective of del(17p)/TP53, or unmutated IGHV. Common grade ≥3 adverse events were infections (12.2%) and bleeding (3%). Grade ≥3 AF occurred in 1.5% of patients. CONCLUSION This real-world study shows that single-agent ibrutinib is an effective therapy for CLL, regardless of age and high-risk molecular features, consistent with clinical trials. Additionally, single-agent ibrutinib was well tolerated, with a low rate of cardiovascular events. This study also emphasized a high molecular testing rate of del(17p)/TP53 mutation and IGHV mutation status in clinical practice according to guideline recommendations.
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Affiliation(s)
| | | | | | | | - Macarena Ortiz
- Hospital Regional Universitario de Málaga, Malaga, Spain
| | | | | | | | | | - Ana Lario
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana Godoy
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Ana Oliveira
- ICO L'Hospitalet, L'Hospitalet de Llobregat, Spain
| | | | | | | | | | - Santiago Osorio
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Fernando Marco
- Hospital Universitario de Basurto, Bilbo, Bizkaia, Spain
| | | | | | | | | | - Alexia Suarez
- Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | | | - Eduardo Ríos
- Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | | | - Rafael Ramos
- Hospital Universitario de Badajoz, Badajoz, Spain
| | - Lucrecia Yáñez
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José Luis Bello
- Hospital Clínico Universitario de Santiago-CHUS, Santiago de Compostela, A Coruña, Spain
| | | | - Daniel Acha
- Medical Department-Hematology Janssen-Cilag, S.A., Madrid, Spain
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Lew TE, Tam CS, Seymour JF. How I treat chronic lymphocytic leukemia after venetoclax. Blood 2021; 138:361-369. [PMID: 33876212 DOI: 10.1182/blood.2020008502] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/29/2021] [Indexed: 12/22/2022] Open
Abstract
Venetoclax-based regimens have expanded the therapeutic options for patients with chronic lymphocytic leukemia (CLL), frequently achieving remissions with undetectable measurable residual disease and facilitating time-limited treatment without chemotherapy. Although response rates are high and durable disease control is common, longer-term follow-up of patients with relapsed and refractory disease, especially in the presence of TP53 aberrations, demonstrates frequent disease resistance and progression. Although the understanding of venetoclax resistance remains incomplete, progressive disease is typified by oligoclonal leukemic populations with distinct resistance mechanisms, including BCL2 mutations, upregulation of alternative BCL2 family proteins, and genomic instability. Although most commonly observed in heavily pretreated patients with disease refractory to fludarabine and harboring complex karyotype, Richter transformation presents a distinct and challenging manifestation of venetoclax resistance. For patients with progressive CLL after venetoclax, treatment options include B-cell receptor pathway inhibitors, allogeneic stem cell transplantation, chimeric antigen receptor T cells, and venetoclax retreatment for those with disease relapsing after time-limited therapy. However, data to inform clinical decisions for these patients are limited. We review the biology of venetoclax resistance and outline an approach to the common clinical scenarios encountered after venetoclax-based therapy that will increasingly confront practicing clinicians.
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MESH Headings
- Allografts
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Drug Resistance, Neoplasm
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunotherapy, Adoptive
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Proto-Oncogene Proteins c-bcl-2/genetics
- Proto-Oncogene Proteins c-bcl-2/metabolism
- Sulfonamides/therapeutic use
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Thomas E Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; and
| | - Constantine S Tam
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - John F Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
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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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Rashid B, Jalal S, Yassin A, Hassan K, Mohamed Z, Ahmed Z, Mahmood T, Shamoon R, Mustafa S, Karam M, Abdullah D, Mohammad S, Abdulrahman L, Yousif RH, Abdulla B, Mohammed N, Getta H, Polus R, Numan G. Impact of clinical staging and demographic data (age and sex) on response to treatment and survival of chronic lymphocytic leukemia patients in Kurdistan Region of Iraq. IRAQI JOURNAL OF HEMATOLOGY 2021. [DOI: 10.4103/ijh.ijh_11_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Acalabrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia: updated phase 2 results. Blood 2020; 135:1204-1213. [PMID: 31876911 DOI: 10.1182/blood.2018884940] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 10/23/2019] [Indexed: 12/31/2022] Open
Abstract
Therapeutic targeting of Bruton tyrosine kinase (BTK) has dramatically improved survival outcomes for patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Acalabrutinib is an oral, highly selective BTK inhibitor that allows for twice-daily dosing due to its selectivity. In this phase 1b/2 study, 134 patients with relapsed/refractory CLL or SLL (median age, 66 years [range, 42-85 years]; median prior therapies, 2 [range, 1-13]) received acalabrutinib 100 mg twice daily for a median of 41 months (range, 0.2-58 months). Median trough BTK occupancy at steady state was 97%. Most adverse events (AEs) were mild or moderate, and were most commonly diarrhea (52%) and headache (51%). Grade ≥3 AEs (occurring in ≥5% of patients) were neutropenia (14%), pneumonia (11%), hypertension (7%), anemia (7%), and diarrhea (5%). Atrial fibrillation and major bleeding AEs (all grades) occurred in 7% and 5% of patients, respectively. Most patients (56%) remain on treatment; the primary reasons for discontinuation were progressive disease (21%) and AEs (11%). The overall response rate, including partial response with lymphocytosis, with acalabrutinib was 94%; responses were similar regardless of genomic features (presence of del(11)(q22.3), del(17)(p13.1), complex karyotype, or immunoglobulin variable region heavy chain mutation status). Median duration of response and progression-free survival (PFS) have not been reached; the estimated 45-month PFS was 62% (95% confidence interval, 51% to 71%). BTK mutation was detected in 6 of 9 patients (67%) at relapse. This updated and expanded study confirms the efficacy, durability of response, and long-term safety of acalabrutinib, justifying its further investigation in previously untreated and treated patients with CLL/SLL. This trial was registered at www.clinicaltrials.gov as #NCT02029443.
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Ganzel C, Wang XV, Rowe JM, Richards SM, Buck G, Marks DI, Litzow MR, Paietta EM, Foroni L, Luger SM, Willman CL, Mullighan CG, Roberts KG, Wiernik PH, Douer D, Lazarus HM, Tallman MS, Goldstone AH. At three years, patients with acute lymphoblastic leukaemia are still at risk for relapse. Results of the international MRC UKALLXII/ECOG E2993 trial. Br J Haematol 2020; 191:37-43. [PMID: 32220069 PMCID: PMC7687130 DOI: 10.1111/bjh.16616] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Abstract
Late relapse [>3 years from complete remission (CR)] in acute lymphoblastic leukaemia (ALL), is unusual. Data from the MRC UKALLXII/ECOG E2993 trial are presented to evaluate the incidence and characteristics of late relapse in adult ALL. Of 1,909 patients, 1,752 (92%) achieved CR and among these 757 (43·2%) relapsed; 691 (91·3%) within three years and 66 (8·7%) beyond. Among these 66 patients, median time to relapse was 47 (37–144) months. Relapse beyond three years occurred in 3·8% of all who achieved CR. The cumulative risk of relapse was 40%, 43% and 45% at three, five and ten years respectively. Out of the 1 752 patients who achieved CR, 11·7% underwent autologous and 40·6% allogeneic transplant, while in CR1. Of the autologous patients, 43·2% relapsed early and 3·4% relapsed late. However, among the allogeneic patients, 13·2% relapsed early and only 1·3% late. The five‐year overall survival from relapse was 5·8% and 20% in the early and late relapse patients respectively. In conclusion, late relapse in adults with ALL is not uncommon, and is associated with better outcome after relapse compared to early relapse.
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Affiliation(s)
- Chezi Ganzel
- Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Xin V Wang
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Jacob M Rowe
- Shaare Zedek Medical Center, Jerusalem, Israel.,Rambam Medical Center, Haifa, Israel
| | | | | | - David I Marks
- University Hospitals Bristol National Health Service Foundation Trust, Bristol, UK
| | | | | | | | | | | | | | | | | | - Dan Douer
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Shibayama H, Teshima T, Choi I, Hatake K, Sekiguchi N, Yoshinari N. Phase I study of ibrutinib in Japanese patients with treatment-naïve chronic lymphocytic leukemia/small lymphocytic lymphoma. J Clin Exp Hematop 2019; 59:179-186. [PMID: 31866619 PMCID: PMC6954169 DOI: 10.3960/jslrt.19023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This phase I study evaluated the safety and efficacy of single-agent ibrutinib in Japanese patients with treatment-naïve chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (aged 20-69 years and ineligible for chemotherapy using fludarabine or cyclophosphamide, or aged ≥70 years). Eight patients received oral ibrutinib 420 mg once daily until progressive disease or unacceptable toxicity. The primary endpoint was safety; secondary endpoints included the overall response rate (ORR). At the time of final analysis (August 22, 2018), eight patients (all with CLL; median age, 68.5 years) had received ibrutinib for a median of 32.2 months (range, 10.4-35.9); all patients had discontinued study treatment, with 50.0% of patients switching to marketing-approved ibrutinib as subsequent anticancer therapy. All patients had ≥1 adverse event (AE); the most common AEs included a decreased platelet count, upper respiratory tract infection, increased lymphocyte count, diarrhea, nasopharyngitis, peripheral edema and rash. Four patients (50.0%) had a total of eight grade ≥3 AEs, most commonly lung infection and decreased neutrophil count. Eight serious AEs were reported in four patients (50.0%); these included a case of muscle hemorrhage (grade 3), decreased neutrophil count (grade 4) that led to dose reduction and one case of fatal cardiac arrest. The ORR was 87.5% (7/8 patients [exact 95% confidence interval 47.3-99.7]). One patient had a complete response, six had a partial response and one had a partial response with lymphocytosis. Ibrutinib had an acceptable safety profile and high ORR in Japanese patients with treatment-naïve CLL.
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14
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Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, Coutre S, Tam CS, Mulligan SP, Jaeger U, Kipps TJ, Moreno C, Montillo M, Burger JA, Byrd JC, Hillmen P, Dai S, Szoke A, Dean JP, Woyach JA. Final analysis from RESONATE: Up to six years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol 2019; 94:1353-1363. [PMID: 31512258 PMCID: PMC6899718 DOI: 10.1002/ajh.25638] [Citation(s) in RCA: 297] [Impact Index Per Article: 59.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022]
Abstract
Ibrutinib, a once-daily oral inhibitor of Bruton's tyrosine kinase, is approved in the United States and Europe for treatment of patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). The phase 3 RESONATE study showed improved efficacy of single-agent ibrutinib over ofatumumab in patients with relapsed/refractory CLL/SLL, including those with high-risk features. Here we report the final analysis from RESONATE with median follow-up on study of 65.3 months (range, 0.3-71.6) in the ibrutinib arm. Median progression-free survival (PFS) remained significantly longer for patients randomized to ibrutinib vs ofatumumab (44.1 vs 8.1 months; hazard ratio [HR]: 0.148; 95% confidence interval [CI]: 0.113-0.196; P˂.001). The PFS benefit with ibrutinib vs ofatumumab was preserved in the genomic high-risk population with del(17p), TP53 mutation, del(11q), and/or unmutated IGHV status (median PFS 44.1 vs 8.0 months; HR: 0.110; 95% CI: 0.080-0.152), which represented 82% of patients. Overall response rate with ibrutinib was 91% (complete response/complete response with incomplete bone marrow recovery, 11%). Overall survival, censored for crossover, was better with ibrutinib than ofatumumab (HR: 0.639; 95% CI: 0.418-0.975). With up to 71 months (median 41 months) of ibrutinib therapy, the safety profile remained consistent with prior reports; cumulatively, all-grade (grade ≥3) hypertension and atrial fibrillation occurred in 21% (9%) and 12% (6%) of patients, respectively. Only 16% discontinued ibrutinib because of adverse events (AEs). These long-term results confirm the robust efficacy of ibrutinib in relapsed/refractory CLL/SLL irrespective of high-risk clinical or genomic features, with no unexpected AEs. This trial is registered at www.clinicaltrials.gov (NCT01578707).
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Affiliation(s)
- Talha Munir
- Department of Haematology St. James's University Hospital Leeds UK
| | | | - Susan O'Brien
- UC Irvine, Chao Family Comprehensive Cancer Center Irvine California
| | - Jacqueline C. Barrientos
- Division of Medical Oncology and Hematology Northwell Health Cancer Institute Lake Success New York
| | - Paul M. Barr
- Wilmot Cancer Institute University of Rochester Medical Center Rochester New York
| | | | - Steven Coutre
- Stanford Cancer Center Stanford University School of Medicine Stanford California
| | - Constantine S. Tam
- Peter MacCallum Cancer Centre St. Vincent's Hospital and University of Melbourne Melbourne Australia
| | | | - Ulrich Jaeger
- Division of Hematology and Hemostaseology Medical University of Vienna Wien Austria
| | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau Autonomous University of Barcelona Barcelona Spain
| | | | - Jan A. Burger
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston Texas
| | - John C. Byrd
- The Ohio State University Comprehensive Cancer Center Columbus Ohio
| | - Peter Hillmen
- The Leeds Teaching Hospitals St. James Institute of Oncology Leeds UK
| | - Sandra Dai
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
| | - Anita Szoke
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
| | - James P. Dean
- Pharmacyclics LLC, an AbbVie Company Sunnyvale California
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15
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Wojdacz TK, Amarasinghe HE, Kadalayil L, Beattie A, Forster J, Blakemore SJ, Parker H, Bryant D, Larrayoz M, Clifford R, Robbe P, Davis ZA, Else M, Howard DR, Stamatopoulos B, Steele AJ, Rosenquist R, Collins A, Pettitt AR, Hillmen P, Plass C, Schuh A, Catovsky D, Oscier DG, Rose-Zerilli MJJ, Oakes CC, Strefford JC. Clinical significance of DNA methylation in chronic lymphocytic leukemia patients: results from 3 UK clinical trials. Blood Adv 2019; 3:2474-2481. [PMID: 31434681 PMCID: PMC6712529 DOI: 10.1182/bloodadvances.2019000237] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/15/2019] [Indexed: 12/24/2022] Open
Abstract
Chronic lymphocytic leukemia patients with mutated immunoglobulin heavy-chain genes (IGHV-M), particularly those lacking poor-risk genomic lesions, often respond well to chemoimmunotherapy (CIT). DNA methylation profiling can subdivide early-stage patients into naive B-cell-like CLL (n-CLL), memory B-cell-like CLL (m-CLL), and intermediate CLL (i-CLL), with differing times to first treatment and overall survival. However, whether DNA methylation can identify patients destined to respond favorably to CIT has not been ascertained. We classified treatment-naive patients (n = 605) from 3 UK chemo and CIT clinical trials into the 3 epigenetic subgroups, using pyrosequencing and microarray analysis, and performed expansive survival analysis. The n-CLL, i-CLL, and m-CLL signatures were found in 80% (n = 245/305), 17% (53/305), and 2% (7/305) of IGHV-unmutated (IGHV-U) cases, respectively, and in 9%, (19/216), 50% (108/216), and 41% (89/216) of IGHV-M cases, respectively. Multivariate Cox proportional analysis identified m-CLL as an independent prognostic factor for overall survival (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.24-0.87; P = .018) in CLL4, and for progression-free survival (HR, 0.25; 95% CI, 0.10-0.57; P = .002) in ARCTIC and ADMIRE patients. The analysis of epigenetic subgroups in patients entered into 3 first-line UK CLL trials identifies m-CLL as an independent marker of prolonged survival and may aid in the identification of patients destined to demonstrate prolonged survival after CIT.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Chromosome Aberrations
- Computational Biology/methods
- DNA Methylation
- Epigenesis, Genetic
- Epigenomics/methods
- Female
- Gene Expression Profiling
- Gene Expression Regulation, Leukemic
- Humans
- Immunoglobulin Heavy Chains/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Male
- Middle Aged
- Mutation
- Neoplasm Staging
- Prognosis
- Proportional Hazards Models
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Affiliation(s)
- Tomasz K Wojdacz
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
- Independent Clinical Epigenetics Laboratory, Pomeranian Medical University, Szczecin, Poland
- Aarhus Institute of Advanced Studies, Aarhus University, Aarhus, Denmark
| | - Harindra E Amarasinghe
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Latha Kadalayil
- Genetic Epidemiology and Bioinformatics, Faculty of Medicine, and
- Faculty of Natural and Environmental Sciences, University of Southampton, Southampton, United Kingdom
| | - Alice Beattie
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Jade Forster
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Stuart J Blakemore
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
- Department I of Internal Medicine, Centre of Excellence in Aging Research, University of Cologne, Cologne, Germany
| | - Helen Parker
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Dean Bryant
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Marta Larrayoz
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
- Division of Hemato-Oncology, Center for Applied Medical Research, University of Navarra, Pamplona, Spain
| | - Ruth Clifford
- Oxford National Institute for Health Research Biomedical Research Centre/Molecular Diagnostic Centre, University of Oxford, Oxford, United Kingdom
| | - Pauline Robbe
- Oxford National Institute for Health Research Biomedical Research Centre/Molecular Diagnostic Centre, University of Oxford, Oxford, United Kingdom
| | - Zadie A Davis
- Department of Molecular Pathology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Monica Else
- Division of Molecular Pathology, The Institute of Cancer Research, London, United Kingdom
| | - Dena R Howard
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Basile Stamatopoulos
- Université Libre de Bruxelles, Laboratory of Clinical Cell Therapy, Jules Bordet Institute, Brussels, Belgium
| | - Andrew J Steele
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Richard Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Andrew Collins
- Genetic Epidemiology and Bioinformatics, Faculty of Medicine, and
| | - Andrew R Pettitt
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Peter Hillmen
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, United Kingdom
| | - Christoph Plass
- Division of Epigenomics and Cancer Risk Factors, The German Cancer Research Center, Heidelberg, Germany; and
| | - Anna Schuh
- Oxford National Institute for Health Research Biomedical Research Centre/Molecular Diagnostic Centre, University of Oxford, Oxford, United Kingdom
| | - Daniel Catovsky
- Division of Molecular Pathology, The Institute of Cancer Research, London, United Kingdom
| | - David G Oscier
- Department of Molecular Pathology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Matthew J J Rose-Zerilli
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
| | - Christopher C Oakes
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jonathan C Strefford
- Cancer Genomics, Cancer Research UK Centre and Experimental Cancer Medicine Centre, Academic Unit of Cancer Sciences, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
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16
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Sylvan SE, Asklid A, Johansson H, Klintman J, Bjellvi J, Tolvgård S, Kimby E, Norin S, Andersson PO, Karlsson C, Karlsson K, Lauri B, Mattsson M, Sandstedt AB, Strandberg M, Österborg A, Hansson L. First-line therapy in chronic lymphocytic leukemia: a Swedish nation-wide real-world study on 1053 consecutive patients treated between 2007 and 2013. Haematologica 2019; 104:797-804. [PMID: 30467205 PMCID: PMC6442960 DOI: 10.3324/haematol.2018.200204] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to investigate long-term outcome following first-line therapy in consecutive chronic lymphocytic leukemia (CLL) patients in a well-defined geographic area: Sweden. All patients diagnosed with CLL (2007-2013) (n=3672) were identified from national registries, screening of patient files identified all (100%) treated first line (n=1053) and for those, an in-depth analysis was performed. End points were overall response rate, progression-free survival (PFS), overall survival (OS), and safety. Median age was 71 years; 53% had Rai stage III-IV and 97% had performance status grade 0-2. Fluorescence in situ hybridization (FISH) was performed in 57% of patients: 15% had del(17p). Chlorambucil + prednisone was used in 39% (5% also received rituximab). Fludarabine+cyclophosphamide+rituximab or fludarabine+cyclophosphamide was used in 43% and bendamustine + rituximab in 6%. Overall response rate was 64%; chlorambucil 43%, fludarabine+cyclophosphamide+rituximab 84%, fludarabine+cyclophosphamide 75% and bendamustine + rituximab 75%. Median PFS and OS was 24 and 58 months, respectively, both were significantly associated (multivariate analysis) with type of treatment, del(17p), performance status, gender, age and geographical region (OS only). Chlorambucil-treated patients had a median PFS and OS of only 9 and 33 months, respectively. Chlorambucil usage declined gradually throughout the study period, but one-third of patients still received chlorambucil + rituximab in 2013. Infections ≥grade III were significantly associated with treatment; chlorambucil 19% versus fludarabine+cyclophosphamide+rituximab 30%. Richter transformation occurred in 5.5% of the patients, equally distributed across therapies. This is the largest retrospective, real-world cohort of consecutive first-line treated CLL patients with a complete follow up. In elderly patients, an unmet need for more effective, well-tolerated therapies was identified.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Bendamustine Hydrochloride/administration & dosage
- Chlorambucil/administration & dosage
- Chromosome Deletion
- Chromosomes, Human, Pair 17/genetics
- Chromosomes, Human, Pair 17/metabolism
- Cyclophosphamide/administration & dosage
- Disease-Free Survival
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Prednisolone/administration & dosage
- Registries
- Retrospective Studies
- Rituximab/administration & dosage
- Survival Rate
- Sweden/epidemiology
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
| | - Anna Asklid
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm
- Department of Oncology, Karolinska University Hospital, Stockholm
| | | | - Jenny Klintman
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund
- Department of Translational Medicine, Lund University
| | - Jenny Bjellvi
- Department of Hematology, Sahlgrenska University Hospital, Gothenburg
| | | | - Eva Kimby
- Department of Internal Medicine Huddinge, Karolinska Institutet, Stockholm
| | - Stefan Norin
- Department of Internal Medicine Huddinge, Karolinska Institutet, Stockholm
| | | | - Claes Karlsson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm
- Department of Hematology, Karolinska University Hospital, Stockholm
| | - Karin Karlsson
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund
| | - Birgitta Lauri
- Department of Hematology, Sunderby Hospital, Sunderbyn-Luleå
| | | | | | | | - Anders Österborg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm
- Department of Hematology, Karolinska University Hospital, Stockholm
| | - Lotta Hansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm
- Department of Hematology, Karolinska University Hospital, Stockholm
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17
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Munakata W, Ando K, Hatake K, Fukuhara N, Kinoshita T, Fukuhara S, Shirasugi Y, Yokoyama M, Ichikawa S, Ohmachi K, Gion N, Aoi A, Tobinai K. Phase I study of tirabrutinib (ONO-4059/GS-4059) in patients with relapsed or refractory B-cell malignancies in Japan. Cancer Sci 2019; 110:1686-1694. [PMID: 30815927 PMCID: PMC6500982 DOI: 10.1111/cas.13983] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/06/2019] [Accepted: 02/20/2019] [Indexed: 02/01/2023] Open
Abstract
We evaluated the safety, efficacy, pharmacokinetics, pharmacodynamics and predictive biomarkers of tirabrutinib, a second-generation, enhanced-selectivity Bruton's tyrosine kinase inhibitor in Japanese patients with relapsed/refractory B-cell non-Hodgkin lymphoma (B-cell NHL) and chronic lymphocytic leukemia (CLL). This was an open-label, multicenter, phase I study. Seventeen patients (male N = 8) with a median age of 70 years were enrolled in 4 dose cohorts (160 mg once daily [N = 3], 320 mg once daily [N = 3], 480 mg once daily [N = 4] and 300 mg twice daily [N = 7]); 4 patients had continued tirabrutinib administration as of 4 January 2018. The maximum tolerated dose was not reached. Pneumonitis (N = 1) was the dose-limiting toxicity for 300 mg twice daily. Common adverse events (AEs) were rash (35.3%) and vomiting (29.4%). Eight patients (47.1%) developed grade ≥3 AEs: neutropenia (23.5%), anemia (11.8%) and leukopenia (11.8%) were frequent. The overall response rate (≥PR) was 76.5% (13/17 patients), including 4 DLBCL patients with no CD79A/B or MYD88 mutations, and 1 CLL patient with a TP53 mutation, providing promising data for future developments. Of 16 patients with measurable lesions during the screening period, 12 showed ≥50% reductions in tumor diameter. In many patients, the tumor size decreased soon after beginning treatment. The maximum serum concentration for tirabrutinib was 611, 1220, 1280 and 886 ng/mL on Day 1 and 484, 971 1940, and 961 ng/mL on Day 28 for Cohorts 1-4, respectively. Tirabrutinib pharmacokinetics were linear, with little accumulation following multiple doses. Tirabrutinib was well tolerated and showed promising efficacy for B-cell NHL/CLL.
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Affiliation(s)
- Wataru Munakata
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Kiyoshi Ando
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Kiyohiko Hatake
- Department of Hematology and Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Noriko Fukuhara
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiro Kinoshita
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
| | - Suguru Fukuhara
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Yukari Shirasugi
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Masahiro Yokoyama
- Department of Hematology and Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Satoshi Ichikawa
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ken Ohmachi
- Department of Hematology and Oncology, Tokai University, Isehara, Japan
| | - Naokazu Gion
- Department of Statistical Analysis, Ono Pharmaceutical Co., Ltd., Osaka, Japan
| | - Arata Aoi
- Department of Oncology Clinical Development Planning, Ono Pharmaceutical Co., Ltd., Osaka, Japan
| | - Kensei Tobinai
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
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18
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Relapsed/Refractory Chronic Lymphocytic Leukemia: Chemoimmunotherapy, Treatment until Progression with Mechanism-Driven Agents or Finite-Duration Therapy? Mediterr J Hematol Infect Dis 2019; 11:e2019024. [PMID: 30858962 PMCID: PMC6402553 DOI: 10.4084/mjhid.2019.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 02/01/2019] [Indexed: 12/19/2022] Open
Abstract
Treatment of relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) has dramatically improved thanks to the development of mechanism-driven agents including drugs that inhibit kinases in the BCR pathway or BCL2. The treating physician has now the opportunity to decide i) which patient can be still offered chemoimmunotherapy as salvage treatment, ii) which patient at relapse is a candidate to receiving, continuous treatment with ibrutinib, idelalisib and rituximab or venetoclax and iii) which patient may benefit from a fixed-duration treatment using the BCL2 antagonist venetoclax in association with rituximab. Ibrutinib is the most actively investigated drug in R/R CLL and data at a 7-year follow-up were reported, showing durable efficacy and favorable efficacy profile. The patients with cardiac disease, hypertension, and anticoagulant therapy are not ideal candidates for continuous therapy with this agent. Idelalisib and rituximab were tested in patients with unfavorable characteristics including cytopenias. The short follow-up and treatment-emergent adverse events limit its role to patients unlikely to get a benefit with other agents. Venetoclax and rituximab is the only effective chemo-free approach for the treatment of R/R with a fixed duration (up to 24 months) schedule capable of inducing deep responses in the majority of cases with a reassuring safety profile. While a deep knowledge of the growing body of scientific evidence is required to inform and guide the appropriate treatment choice and management, physicians cannot disregard the growing problem of sustainability.
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19
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Reyes C, Engel-Nitz NM, DaCosta Byfield S, Ravelo A, Ogale S, Bancroft T, Anderson A, Chen M, Matasar M. Cost of Disease Progression in Patients with Chronic Lymphocytic Leukemia, Acute Myeloid Leukemia, and Non-Hodgkin's Lymphoma. Oncologist 2019; 24:1219-1228. [PMID: 30808814 DOI: 10.1634/theoncologist.2018-0019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/08/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION To reduce health care costs and improve care, payers and physician groups are switching to quality-based and episodic or bundled-care models. Disease progression and associated costs may affect these models, particularly if such programs do not account for differences in disease severity and progression risk within the cohort. This study estimated the incremental cost of disease progression in patients diagnosed with chronic lymphoid leukemia (CLL), acute myeloid leukemia (AML), and non-Hodgkin's lymphoma (NHL) and compared costs among patients with and without progression. METHODS This was a retrospective study using U.S. administrative claims data from commercial and Medicare Advantage health care enrollees with evidence of CLL, AML, and NHL and systemic antineoplastic agent use from July 1, 2006 to August 31, 2014. Outcome measures included disease progression, 12-month health care costs, and 3-year cumulative predictive health care costs. RESULTS Of 1,056 patients with CLL, 514 patients with AML, and 7,601 patients with NHL, 31.1% of patients with CLL, 63.8% of those with AML, and 36.9% of those with NHL had evidence of disease progression. Among patients with CLL and NHL, adjusted and unadjusted health care costs were significantly higher among progressors versus nonprogressors. Per-patient-per-month costs, accounting for variable follow-up time, were almost twice as high among progressors versus nonprogressors in patients with CLL, AML, and NHL. In each of the three cancer types, the longer disease progression was delayed, the lower the health care costs. CONCLUSION Progression of CLL, AML, and NHL was associated with higher health care costs over a 12-month period. Delaying cancer progression resulted in a substantial cost reduction in patients with all three cancer types. IMPLICATIONS FOR PRACTICE Data on the rates and incremental health care costs of disease progression in patients with hematologic malignancies are lacking. This study estimated the incremental costs of disease progression in patients diagnosed with chronic lymphocytic leukemia, acute myeloid leukemia, and non-Hodgkin's lymphoma and compared health care costs in patients with and without evidence of disease progression in a real-world population. The data obtained in this study will assist future studies in quantifying the cost impact of decreased progression rates and will inform payers and physician groups about setting rates for episode and bundled payment programs.
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MESH Headings
- Aged
- Antineoplastic Agents/economics
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Disease Progression
- Drug Costs
- Female
- Health Care Costs
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Myeloid, Acute/economics
- Leukemia, Myeloid, Acute/epidemiology
- Lymphoma, Non-Hodgkin/economics
- Lymphoma, Non-Hodgkin/epidemiology
- Male
- Medicare
- Middle Aged
- Retrospective Studies
- United States/epidemiology
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Affiliation(s)
| | | | | | | | | | | | | | - May Chen
- South Bay Oncology Hematology, San Jose, California, USA
| | - Matthew Matasar
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
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20
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Abstract
Assays that measure DNA damage and repair are critical in evaluating the extent to which therapeutic agents damage DNA and in identifying whether DNA repair can limit the toxicity of chemotherapy. The COMET assays described in this guide should help readers evaluate single and double-strand breaks cause by chemotherapeutic agents and also monitor the ability of the cells to repair such damage. The EJDR assay described is a valuable tool to assess the ability of drugs and DNA repair proteins to modulate DNA repair capacity. Finally, the immunofluorescence assay described should allow accurate assessments of DNA damage and the kinetics of repair as measured by Ɣ-H2AX foci. This procedure can also be used to mechanistically investigate the recruitment of specific DNA damage and repair proteins in CLL cells.
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Affiliation(s)
- Tzung-Huei Lai
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Deepa Sampath
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA.
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21
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Li Y, Huang K, Liu L, Qu Y, Huang Y, Wu Y, Wei J. Effects of complement and serum IgG on rituximab-dependent natural killer cell-mediated cytotoxicity against Raji cells. Oncol Lett 2018; 17:339-347. [PMID: 30655772 PMCID: PMC6313095 DOI: 10.3892/ol.2018.9630] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 10/04/2018] [Indexed: 12/24/2022] Open
Abstract
Accumulating evidence indicates that the anti-CD20 monoclonal antibody rituximab significantly improves the clinical prognosis of patients with non-Hodgkin lymphoma and chronic lymphocytic leukemia. However, a number of patients relapse or fail to respond to rituximab. To further understand the cause of this, polymorphisms of FcγRIIIa were initially detected in healthy volunteers. Subsequently, the rituximab-dependent natural killer (NK) cell-mediated cytotoxicity of different FcγRIIIa genotypes was assessed by a cytotoxicity assay in vitro. Ultimately, the effect of human serum immunoglobulin (Ig) G and complement on rituximab-dependent NK cell-mediated cytotoxicity was evaluated in vitro. It was revealed that FcγRIIIa polymorphisms were associated with the antibody-dependent cell-mediated cytotoxicity (ADCC) of NK cells. In addition, the ADCC of NK cells with FcγRIIIa-158 V/V was increased compared with that of FcγRIIIa-158 V/F. The serum IgG and rituximab Fc segment was able to bind competitively with NK cell FcγRIIIa. It was observed that serum IgG inhibited, whereas complement enhanced rituximab-induced NK-cell mediated ADCC. Therefore, various agents administered synchronously with rituximab may modulate the efficacy of this agent and ultimately its toxicity against tumor cells.
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Affiliation(s)
- Yang Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China.,Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Ke Huang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China.,Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Ling Liu
- Department of Pediatric, Affiliatied Hospital of Guangdong Medical University, Zhanjiang, Guangdong 524000, P.R. China
| | - Yuhua Qu
- Department of Pediatrics, Guang Zhou Women and Children's Medical Center, Guangzhou, Guangdong 510120, P.R. China
| | - Yan Huang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China.,Department of Pediatric Hematology/Oncology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Yanfeng Wu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China.,Biotherapy Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
| | - Jing Wei
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China.,Medical Research Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510120, P.R. China
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22
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Huang C, Tu Y, Freter CE. Fludarabine-resistance associates with ceramide metabolism and leukemia stem cell development in chronic lymphocytic leukemia. Oncotarget 2018; 9:33124-33137. [PMID: 30237856 PMCID: PMC6145702 DOI: 10.18632/oncotarget.26043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/13/2018] [Indexed: 01/13/2023] Open
Abstract
Fludarabine (flu) -containing regimens such as flu, cyclophosphamide and rituximab have been established as one of the standard first line therapy in medically-fit chronic lymphocytic leukemia (CLL) patients. Therefore, flu-refractory (primary flu-insensitivity or flu-caused relapse) remains a major problem causing treatment failure for CLL patients. We isolated the peripheral blood mononuclear cells (PBMCs) from CLL patients and treated with flu to find flu-refractory cases, and established flu-resistant clonal cells to study molecular mechanism of flu-resistance. By comparing parental MEC-2 cells, a human CLL cell line, we found that flu-resistant clonal cells were significantly increased lethal dose 50 of flu concentration, and up-regulated expression of P-glycoprotein, a drug-resistant marker, glucosylceramide synthase (GCS), an enzyme that can convert ceramide to glucosylceramide, and CD34, a leukemia stem cell marker. Overexpression of GCS leads to promptly elimination of cellular ceramide levels and accumulation of glucosylceramide, which reduces apoptosis and promotes survival and proliferation of flu-resistant clonal cells. Furthermore, we demonstrated that the accumulation of glucosylceramide can be blocked by PDMP to restore flu-sensitivity in flu-resistant clonal cells. We also found that elevating glucosylceramide levels in flu-resistant clonal cells was associated with up-regulation of GCS and CD34 expression. Importantly, overexpression of GCS or CD34 was also determined in flu-refractory PBMCs. Our results show that flu-resistance is associated with the alteration of ceramide metabolism and the development of leukemia stem cell-like cells. The flu-resistance can be reversed by GCS inhibition as a novel strategy for overcoming drug resistance.
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Affiliation(s)
- Chunfa Huang
- Division of Hematology/Oncology, Department of Internal Medicine, School of Medicine, Saint Louis University, Saint Louis, MO, 63110, USA
| | - Yifan Tu
- Division of Hematology/Oncology, Department of Internal Medicine, School of Medicine, Saint Louis University, Saint Louis, MO, 63110, USA
| | - Carl E Freter
- Division of Hematology/Oncology, Department of Internal Medicine, School of Medicine, Saint Louis University, Saint Louis, MO, 63110, USA
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23
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High-risk chronic lymphocytic leukemia in the era of pathway inhibitors: integrating molecular and cellular therapies. Blood 2018; 132:892-902. [DOI: 10.1182/blood-2018-01-826008] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 07/06/2018] [Indexed: 12/16/2022] Open
Abstract
AbstractHigh-risk chronic lymphocytic leukemia (CLL) has been defined by clinical and/or genetic resistance (TP53 abnormalities) to treatment with chemoimmunotherapy (CIT). With the availability of pathway inhibitors (PIs), such as kinase inhibitors and BCL2 antagonists, the outlook of CIT-resistant patients has dramatically improved. Here, we propose a revision of the concept of high-risk CLL, driven by TP53 abnormalities and response to treatment with PI. CLL high-risk-I, CIT-resistant is defined by clinically CIT-resistant disease with TP53 aberrations, but fully responsive to PI. This category is largely the domain of PI-based therapy, and cellular therapy (ie, allogeneic hematopoietic cell transplantation) remains an option only in selected patients with low individual procedure-related risk. In CLL high-risk-II, CIT- and PI-resistant, characterized by increasing exhaustion of pharmacological treatment possibilities, cellular therapies (including chimeric antigen receptor-engineered T cells) should be considered in patients eligible for these procedures. Moreover, molecular and cellular therapies are not mutually exclusive and could be used synergistically to exploit their full potential.
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24
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Barnes JI, Divi V, Begaye A, Wong R, Coutre S, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of ibrutinib as first-line therapy for chronic lymphocytic leukemia in older adults without deletion 17p. Blood Adv 2018; 2:1946-1956. [PMID: 30097461 PMCID: PMC6093732 DOI: 10.1182/bloodadvances.2017015461] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/18/2018] [Indexed: 12/22/2022] Open
Abstract
Ibrutinib is a novel oral therapy that has shown significant efficacy as initial treatment of chronic lymphocytic leukemia (CLL). It is a high-cost continuous therapy differing from other regimens that are given for much shorter courses. Our objective was to evaluate the cost-effectiveness of ibrutinib for first-line treatment of CLL in patients older than age 65 years without a 17p deletion. We developed a semi-Markov model to analyze the cost-effectiveness of ibrutinib vs a comparator therapy from a US Medicare perspective. No direct comparison between ibrutinib and the best available treatment alternative, obinutuzumab plus chlorambucil (chemoimmunotherapy), exists. Therefore, we compared ibrutinib to a theoretical treatment alternative, which was modeled to confer the effectiveness of an inferior treatment (chlorambucil alone) and the costs and adverse events of chemoimmunotherapy, which would provide ibrutinib with the best chance of being cost-effective. Even so, the incremental cost-effectiveness ratio of ibrutinib vs the modeled comparator was $189 000 per quality-adjusted life-year (QALY) gained. To reach a willingness-to-pay threshold (WTP) of $150 000 per QALY, the monthly cost of ibrutinib would have to be at most $6800, $1700 less than the modeled cost of $8500 per month (a reduction of $20 400 per year). When the comparator efficacy is increased to more closely match that seen in trials evaluating chemoimmunotherapy, ibrutinib costs more than $262 000 per QALY gained, and the monthly cost of ibrutinib would need to be lowered to less than $5000 per month to be cost-effective. Ibrutinib is not cost-effective as initial therapy at a WTP threshold of $150 000 per QALY gained.
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Affiliation(s)
- James I Barnes
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine
| | - Vasu Divi
- Department of Otolaryngology-Head and Neck Surgery
| | | | - Russell Wong
- Department of Management Science and Engineering, and
| | - Steven Coutre
- Division of Hematology, Stanford University School of Medicine, Stanford University, Stanford, CA
| | - Douglas K Owens
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine
| | - Jeremy D Goldhaber-Fiebert
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine
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25
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Joffe E, Goldschmidt N, Bairey O, Fineman R, Ruchlemer R, Rahimi-Levene N, Shvidel L, Greenbaum U, Aviv A, Tadmor T, Braester A, Arad A, Polliack A, Herishanu Y. Outcomes of second-line treatment after fludarabine cyclophosphamide and rituximab in patients with chronic lymphocytic leukemia outside clinical trials. Eur J Haematol 2018; 101:399-406. [PMID: 29949186 DOI: 10.1111/ejh.13129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/11/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate disease characteristics and long-term outcomes in patients requiring second-line treatment following fludarabine, cyclophosphamide, and rituximab (FCR), for relapsed/refractory disease (R/R), or following discontinuation due to toxicities. METHOD A retrospective analysis of 126 chronic lymphocytic leukemia patients treated with frontline FCR: 63 received second-line treatment (41 relapsed, nine refractory [SD/PD], 13 prior toxicity). Time to next treatment (TTNT) was calculated from beginning FCR to initiation of second-line therapy. Overall and event-free survival was calculated from initiation of salvage treatment (OS2/EFS2). RESULTS Median follow-up for the entire cohort was 67 and 37 months from second-line therapy. TTNT < 24 months was associated with shorter OS2 and EFS2 similar to those observed with primary refractory disease (OS2 19 and 23 months; EFS2 12 and 9 months for TTNT < 24 months and SD/PD, respectively). TTNT ≥ 24 months (71% chemotherapy-based second-line), had longer OS2 and EFS2 (48 and 20 months). Among the 13 patients receiving second-line therapy after discontinuing FCR due to toxicity EFS2 was 41 months (59 months from initiation of FCR). CONCLUSION With limitations of sample size and treatment heterogeneity, patients progressing <24 months following FCR have poor outcomes, similar to refractory patients, while longer remissions are indicative of a chemoimmunotherapy sensitive disease. Patients who discontinue FCR for toxicities may achieve excellent outcomes with subsequent treatment.
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Affiliation(s)
- Erel Joffe
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Osnat Bairey
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Riva Fineman
- Department of Hematology, Rambam Medical Center, Haifa, Israel
| | - Rosa Ruchlemer
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Lev Shvidel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel.,Department of Hematology, Kaplan Medical Center, Rehovot, Israel
| | - Uri Greenbaum
- Soroka Medical Center, Beer Sheba and Ben-Gurion University, Beer Sheba, Israel
| | - Ariel Aviv
- Department of Hematology, Emek Medical Center, Afula, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Andrea Braester
- Department of Hematology, Western Galilee Hospital, Nahariya, Israel
| | - Ariela Arad
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
| | - Aaron Polliack
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yair Herishanu
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Hematology Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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26
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Schuh AH, Parry-Jones N, Appleby N, Bloor A, Dearden CE, Fegan C, Follows G, Fox CP, Iyengar S, Kennedy B, McCarthy H, Parry HM, Patten P, Pettitt AR, Ringshausen I, Walewska R, Hillmen P. Guideline for the treatment of chronic lymphocytic leukaemia: A British Society for Haematology Guideline. Br J Haematol 2018; 182:344-359. [PMID: 30009455 DOI: 10.1111/bjh.15460] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna H Schuh
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Nilima Parry-Jones
- Department of Haematology, Aneurin Bevan University Health Board, Abergavenny, UK
| | - Niamh Appleby
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust and Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | | | | | | | - Christopher P Fox
- Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ben Kennedy
- Department of Haematology, University Hospital Leicester, Leicester, UK
| | - Helen McCarthy
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Helen M Parry
- NIHR-ACL Haematology, University of Birmingham, Birmingham, UK
| | | | | | | | - Renata Walewska
- Haematology, Bournemouth and Christchurch Hospitals, Bournemouth, UK
| | - Peter Hillmen
- Haematology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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27
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Jain N, Thompson P, Ferrajoli A, Nabhan C, Mato AR, O'Brien S. Approaches to Chronic Lymphocytic Leukemia Therapy in the Era of New Agents: The Conundrum of Many Options. Am Soc Clin Oncol Educ Book 2018; 38:580-591. [PMID: 30231393 DOI: 10.1200/edbk_200691] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Three small molecule inhibitors have been approved for the treatment of chronic lymphocytic leukemia (CLL) in the last 4 years. Ibrutinib, idelalisib, and venetoclax are oral agents with excellent efficacy and different toxicity profiles. Issues discussed herein include the current role for chemoimmunotherapy in CLL, the use of oral inhibitors in older patients, and the sequencing of these molecules in daily practice.
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Affiliation(s)
- Nitin Jain
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Philip Thompson
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Alessandra Ferrajoli
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Chadi Nabhan
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Anthony R Mato
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Susan O'Brien
- From the Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Cardinal Health Specialty Solutions, Chicago, IL; Chronic Lymphocytic Leukemia Program, Memorial Sloan Kettering Cancer Center, New York, NY; Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
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28
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Strati P, Jain N, O'Brien S. Chronic Lymphocytic Leukemia: Diagnosis and Treatment. Mayo Clin Proc 2018; 93:651-664. [PMID: 29728204 DOI: 10.1016/j.mayocp.2018.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/30/2018] [Accepted: 03/02/2018] [Indexed: 12/27/2022]
Abstract
The complexity of the treatment of patients with chronic lymphocytic leukemia has increased substantially over the past several years as a consequence of the advent of novel biological agents such as ibrutinib, idelalisib, and venetoclax, as well as increasingly potent anti-CD20 monoclonal antibodies. In addition, the identification of molecular predictive markers and the introduction of more sensitive and sophisticated techniques to assess minimal residual disease have allowed optimization of the use of chemoimmunotherapy and targeted therapies and may become standard of care in the future. This review summarizes the diagnosis, prognostication, and treatment of patients with chronic lymphocytic leukemia with emphasis on new prognostic and predictive factors and novel treatment strategies.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
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Affiliation(s)
- Paolo Strati
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA.
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29
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Affiliation(s)
- A Cuneo
- Department of Radiotherapy, Hematology Unit, University of Ferrara, Ferrara
| | - R Foà
- Department of Cellular Biotechnologies and Hematology, Policlinico Umberto I, Sapienza University, Rome, Italy
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30
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O'Brien S, Furman RR, Coutre S, Flinn IW, Burger JA, Blum K, Sharman J, Wierda W, Jones J, Zhao W, Heerema NA, Johnson AJ, Luan Y, James DF, Chu AD, Byrd JC. Single-agent ibrutinib in treatment-naïve and relapsed/refractory chronic lymphocytic leukemia: a 5-year experience. Blood 2018; 131:1910-1919. [PMID: 29437592 PMCID: PMC5921964 DOI: 10.1182/blood-2017-10-810044] [Citation(s) in RCA: 307] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 01/24/2018] [Indexed: 12/25/2022] Open
Abstract
We previously reported durable responses and manageable safety of ibrutinib from a 3-year follow-up of treatment-naïve (TN) older patients (≥65 years of age) and relapsed/refractory (R/R) patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). We now report on long-term efficacy and safety with median follow-up of 5 years in this patient population with TN (N = 31) and R/R (N = 101) CLL/SLL. With the current 5-year follow-up, ibrutinib continues to yield a high overall response rate of 89%, with complete response rates increasing over time to 29% in TN patients and 10% in R/R patients. The median progression-free survival (PFS) was not reached in TN patients. The 5-year PFS rate was 92% in TN patients and 44% in R/R patients. Median PFS in R/R patients was 51 months; in those with del(11q), del(17p), and unmutated IGHV, it was 51, 26, and 43 months, respectively, demonstrating long-term efficacy of ibrutinib in some high-risk subgroups. Survival outcomes were less robust for R/R patients with del(17p) and those who received more prior therapies. The onset of grade ≥3 cytopenias, such as neutropenia and thrombocytopenia, decreased over time. Treatment--limiting adverse events were more frequent during the first year compared with subsequent periods. These results demonstrate sustained efficacy and acceptable tolerability of ibrutinib over an extended time, providing the longest experience for Bruton tyrosine kinase inhibitor treatment in patients with CLL/SLL. These trials were registered at www.clinicaltrials.gov as #NCT01105247 and #NCT01109069.
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MESH Headings
- Adenine/analogs & derivatives
- Adult
- Aged
- Aged, 80 and over
- Disease-Free Survival
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Piperidines
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Survival Rate
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Affiliation(s)
- Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Richard R Furman
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Steven Coutre
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, CA
| | - Ian W Flinn
- Sarah Cannon Research Institute, Nashville, TN
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristie Blum
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Jeff Sharman
- Willamette Valley Cancer Institute and Research Center, Springfield, OR; and
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey Jones
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Weiqiang Zhao
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Nyla A Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Amy J Johnson
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ying Luan
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - Alvina D Chu
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - John C Byrd
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
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31
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Ammann EM, Shanafelt TD, Wright KB, McDowell BD, Link BK, Chrischilles EA. Updating survival estimates in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma (CLL/SLL) based on treatment-free interval length. Leuk Lymphoma 2018; 59:643-649. [PMID: 28718694 PMCID: PMC5769448 DOI: 10.1080/10428194.2017.1349905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We hypothesized that the length of treatment-free survival following (a) initial diagnosis and (b) first-line treatment would be associated with improved subsequent five-year relative survival (RS5) in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma (CLL/SLL). 19,879 patients incident CLL/SLL cases (median age = 76 years) were identified from SEER-Medicare. RS5 improved from 0.73 (95% CI: 0.72, 0.74) at diagnosis to 0.81 (95% CI: 0.80, 0.82) at year 1 and 0.89 (95% CI: 0.83, 0.96) at year 10 among those who had not received treatment. In our analysis of survival patterns following first-line treatment, RS5 improved from 0.55 (95% CI: 0.53, 0.57) at initiation of first-line treatment to 0.84 (95% CI: 0.75, 0.92) among patients who had not been retreated at year 5 following first-line therapy. Longer periods of treatment-free survival following initial diagnosis and first-line treatment were both predictive of meaningfully improved prognosis in CLL/SLL patients.
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MESH Headings
- Aged
- Aged, 80 and over
- Combined Modality Therapy
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Longitudinal Studies
- Male
- Prognosis
- Quality of Life
- SEER Program
- Survival Rate
- Time Factors
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Affiliation(s)
- Eric M. Ammann
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | | | - Kara B. Wright
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | | | - Brian K. Link
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Elizabeth A. Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
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32
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Kersting S, Neppelenbroek SI, Visser HP, van Gelder M, Levin MD, Mous R, Posthuma W, van der Straaten HM, Kater AP. Clinical Practice Guidelines for Diagnosis and Treatment of Chronic Lymphocytic Leukemia (CLL) in The Netherlands. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:52-57. [DOI: 10.1016/j.clml.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/24/2017] [Accepted: 09/15/2017] [Indexed: 11/30/2022]
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33
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Ammann EM, Shanafelt TD, Larson MC, Wright KB, McDowell BD, Link BK, Chrischilles EA. Time to Second-line Treatment and Subsequent Relative Survival in Older Patients With Relapsed Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2017; 17:e11-e25. [PMID: 28802891 PMCID: PMC5769450 DOI: 10.1016/j.clml.2017.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/10/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Novel targeted therapies offer excellent short-term outcomes in patients with chronic lymphocytic leukemia and small lymphocytic lymphoma (CLL/SLL). However, there is disagreement over how widely these therapies should be used in place of standard chemo-immunotherapy (CIT). We investigated whether stratification on the length of the interval between first-line (T1) and second-line (T2) treatments could identify a subgroup of older patients with relapsed CLL/SLL with an expectation of normal overall survival, and for whom CIT could be an acceptable treatment choice. PATIENTS AND METHODS Patients with relapsed CLL/SLL who received T2 were identified from the SEER-Medicare Linked Database. Five-year relative survival (RS5; ie, the ratio of observed survival to expected survival based on population life tables) was assessed after stratifying patients on the interval between T1 and T2. We then validated our findings in the Mayo Clinic CLL Database. RESULTS Among 1974 SEER-Medicare patients (median age = 77 years) who received T2 for relapsed CLL/SLL, longer time-to-retreatment was associated with a modestly improved prognosis (P = .01). However, even among those retreated ≥ 3 years after T1, survival was poor compared with the general population (RS5 = 0.50 or lower in SEER-Medicare). Similar patterns were observed in the younger Mayo validation cohort, although prognosis was better overall among the Mayo patients, and patients with favorable fluorescence in situ hybridization retreated ≥ 3 years after T1 had close to normal expected survival (RS5 = 0.87). CONCLUSION Further research is needed to quantify the degree to which targeted therapies provide meaningful improvements over CIT in long-term outcomes for older patients with relapsed CLL/SLL.
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Affiliation(s)
- Eric M Ammann
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA.
| | | | | | - Kara B Wright
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
| | | | - Brian K Link
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA; Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Elizabeth A Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA; Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA
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Ahn IE, Farber CM, Davids MS, Grinblatt DL, Kay NE, Lamanna N, Mato A, Nabhan C, Kiselev P, Swern AS, Flick ED, Sullivan K, Sharman JP, Flowers CR. Early progression of disease as a predictor of survival in chronic lymphocytic leukemia. Blood Adv 2017; 1:2433-2443. [PMID: 29296893 PMCID: PMC5729627 DOI: 10.1182/bloodadvances.2017011262] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/23/2017] [Indexed: 01/01/2023] Open
Abstract
Chemoimmunotherapy for chronic lymphocytic leukemia (CLL) promotes clonal evolution of aggressive clones, which in some patients may lead to early progression of disease (POD). We studied the prognostic value of early POD in a cohort of patients with CLL enrolled between 2010 and 2014 in the Connect CLL Registry. Overall, 829 eligible patients receiving first-line therapy were categorized into 3 groups: early POD (progression <2 years after treatment initiation), late POD (progression ≥2 years after treatment initiation), and no POD as of 1 May 2017. Baseline demographics, treatment characteristics, and overall survival (OS) were analyzed. Logistic regression models identified independent predictors of early POD; Cox regression models were used to evaluate the risk of early POD. With a median follow-up of 48.8 months, 209 (25.2%), 162 (19.5%), and 458 (55.3%) patients had early, late, and no POD, respectively. Patients with early POD were older and had inferior response to similar first-line treatment regimens vs late and no POD groups (overall response rate: 53% vs 80% vs 84%). Patients with early POD were more likely to have unfavorable-risk cytogenetics (del[11q]/del[17p]) than patients with no POD (34% vs 20%; P = .04). Early POD was associated with an inferior OS across all patients (hazard ratio, 3.6; 95% confidence interval, 2.6-5.1; P < .01) and in patients treated with fludarabine, cyclophosphamide plus rituximab, and bendamustine plus rituximab (P < .05). Early POD within 2 years of first-line therapy is a robust clinical prognostic factor for inferior OS in patients with CLL. The Connect CLL Registry was registered at www.clinicaltrials.gov as #NCT01081015.
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Affiliation(s)
- Inhye E Ahn
- Medical Oncology Service, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | | | | | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Nicole Lamanna
- Leukemia Service, Division of Hematology and Oncology, Department of Medicine, New York-Presbyterian/Columbia University Medical Center, New York, NY
| | - Anthony Mato
- Center for Chronic Lymphocytic Leukemia, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | | - Jeff P Sharman
- Willamette Valley Cancer Institute, US Oncology, Springfield, OR; and
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Said R, Tsimberidou AM. Obinutuzumab for the treatment of chronic lymphocytic leukemia and other B-cell lymphoproliferative disorders. Expert Opin Biol Ther 2017; 17:1463-1470. [PMID: 28893099 PMCID: PMC6166403 DOI: 10.1080/14712598.2017.1377178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Chemoimmunotherapeutic regimens using the anti-CD20 antibody rituximab improved significantly the survival rates in various B-cell lymphoproliferative disorders (LPDs), including chronic lymphocytic leukemia (CLL). The next-generation CD20 antibody obinutuzumab represents an addition to the drug armamentarium used for the therapeutic management of patients with LPDs. Areas covered: Herein, the authors discuss the biochemical and conformational engineering of obinutuzumab to increase antibody-dependent cell-mediated cytotoxicity and direct cell death. They also describe the available preclinical data on obinutuzumab's role in B-cell LPDs. Furthermore, the authors summarize the Phase I and II clinical trials of obinutuzumab, focusing on the main pharmacokinetic/pharmacodynamic characteristics, the most common clinically significant adverse events, dose optimization, and clinical outcomes of patients with CLL and other B-cell LPDs treated with obinutuzumab as monotherapy or in combination with other agents. To put these data in perspective, the use of obinutuzumab is compared with that of rituximab in CLL and other B-cell LPDs. Expert opinion: Clinical trials have demonstrated that obinutuzumab is well tolerated. The novel mechanism of action of obinutuzumab is associated with significant efficacy in CLL and other B-cell LPDs. Ongoing clinical trials are expected to determine the optimal use of obinutuzumab in these diseases.
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MESH Headings
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antigens, CD20/immunology
- Antineoplastic Agents, Alkylating/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/pharmacokinetics
- Antineoplastic Agents, Immunological/therapeutic use
- Clinical Trials as Topic
- Drug Therapy, Combination
- Half-Life
- Humans
- Leukemia, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Neutropenia/etiology
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Affiliation(s)
- Rabih Said
- a Department of Oncology , University of Balamand, St. George Hospital University Medical Center , Beirut , Lebanon
- b Department of Investigational Cancer Therapeutics , MD Anderson Cancer Center , Houston , TX , USA
| | - Apostolia M Tsimberidou
- b Department of Investigational Cancer Therapeutics , MD Anderson Cancer Center , Houston , TX , USA
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36
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37
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Extended follow-up and impact of high-risk prognostic factors from the phase 3 RESONATE study in patients with previously treated CLL/SLL. Leukemia 2017; 32:83-91. [PMID: 28592889 PMCID: PMC5770586 DOI: 10.1038/leu.2017.175] [Citation(s) in RCA: 188] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/11/2017] [Accepted: 05/23/2017] [Indexed: 12/14/2022]
Abstract
In the phase 3 RESONATE study, ibrutinib demonstrated superior progression-free survival (PFS), overall survival (OS) and overall response rate (ORR) compared with ofatumumab in relapsed/refractory CLL patients with high-risk prognostic factors. We report updated results from RESONATE in these traditionally chemotherapy resistant high-risk genomic subgroups at a median follow-up of 19 months. Mutations were detected by Foundation One Heme Panel. Baseline mutations in the ibrutinib arm included TP53 (51%), SF3B1 (31%), NOTCH1 (28%), ATM (19%) and BIRC3 (14%). Median PFS was not reached, with 74% of patients randomized to ibrutinib alive and progression-free at 24 months. The improved efficacy of ibrutinib vs ofatumumab continues in all prognostic subgroups including del17p and del11q. No significant difference within the ibrutinib arm was observed for PFS across most genomic subtypes, although a subset carrying both TP53 mutation and del17p had reduced PFS compared with patients with neither abnormality. Reduced PFS or OS was not evident in patients with only del17p. PFS was significantly better for ibrutinib-treated patients in second-line vs later lines of therapy. The robust clinical activity of ibrutinib continues to show ongoing efficacy and acceptable safety consistent with prior reports, independent of various known high-risk mutations.
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38
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Whole-genome sequencing of chronic lymphocytic leukaemia reveals distinct differences in the mutational landscape between IgHV mut and IgHV unmut subgroups. Leukemia 2017; 32:332-342. [PMID: 28584254 PMCID: PMC5808074 DOI: 10.1038/leu.2017.177] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/18/2017] [Accepted: 05/17/2017] [Indexed: 01/02/2023]
Abstract
Chronic lymphocytic leukaemia (CLL) consists of two biologically and clinically distinct subtypes defined by the abundance of somatic hypermutation (SHM) affecting the Ig variable heavy-chain locus (IgHV). The molecular mechanisms underlying these subtypes are incompletely understood. Here, we present a comprehensive whole-genome sequencing analysis of somatically acquired genetic events from 46 CLL patients, including a systematic comparison of coding and non-coding single-nucleotide variants, copy number variants and structural variants, regions of kataegis and mutation signatures between IgHVmut and IgHVunmut subtypes. We demonstrate that one-quarter of non-coding mutations in regions of kataegis outside the Ig loci are located in genes relevant to CLL. We show that non-coding mutations in ATM may negatively impact on ATM expression and find non-coding and regulatory region mutations in TCL1A, and in IgHVunmut CLL in IKZF3, SAMHD1,PAX5 and BIRC3. Finally, we show that IgHVunmut CLL is dominated by coding mutations in driver genes and an aging signature, whereas IgHVmut CLL has a high incidence of promoter and enhancer mutations caused by aberrant activation-induced cytidine deaminase activity. Taken together, our data support the hypothesis that differences in clinical outcome and biological characteristics between the two subgroups might reflect differences in mutation distribution, incidence and distinct underlying mutagenic mechanisms.
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Murthy V, Weaving S, Paneesha S. Imbruvica®▾(ibrutinib) patient support programme for chronic lymphocytic leukaemia and mantle cell lymphoma. ACTA ACUST UNITED AC 2017; 26:S20-S25. [DOI: 10.12968/bjon.2017.26.10.s20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Vidhya Murthy
- Consultant Haematologist, Heart of England NHS Foundation Trust
| | - Susan Weaving
- Haematology Clinical Nurse Specialist, Heart of England NHS Foundation Trust
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40
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Itchaki G, Brown JR. Lenalidomide in the treatment of chronic lymphocytic leukemia. Expert Opin Investig Drugs 2017; 26:633-650. [PMID: 28388253 DOI: 10.1080/13543784.2017.1313230] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Lenalidomide is an immunomodulatory drug (IMiD) with a unique mode of action (MOA) that may vary across disease-type. It is currently approved in multiple myeloma (MM), myelodysplastic syndrome (MDS) and mantle cell lymphoma (MCL), yet is also clinically active in a host of lymphoproliferative diseases, including chronic lymphocytic leukemia (CLL). Due to its protean effects on the immune system, lenalidomide may be particularly appealing in CLL, which is distinct in its ability to evade immune recognition and cause immunosuppression. Areas covered: This review recaps the biological mechanisms of lenalidomide specific for CLL, and summarizes the clinical data in previously untreated and relapsed/refractory (R/R) CLL patients, with emphasis on toxicity. Moreover, lenalidomide treatment is put into the context of the highly effective targeted agents that are drastically changing the therapeutic approach in CLL. Expert opinion: Lenalidomide is a potent drug in CLL, both in first line and relapse. However, in comparison to other newly available agents, lenalidomide has slow onset of efficacy and notable toxicity profile that limits both its single agent use and combinations with chemotherapy. Future trials will hopefully direct our ability to harness lenalidomide MOA to best incorporate it in the rapidly evolving landscape of CLL treatment.
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Affiliation(s)
- Gilad Itchaki
- a Department of Medical Oncology , Dana Farber Cancer Institute , Boston , MA , USA
| | - Jennifer R Brown
- a Department of Medical Oncology , Dana Farber Cancer Institute , Boston , MA , USA
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41
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Strati P. Treatment for relapsed or refractory chronic lymphocytic leukaemia: an ongoing challenge. LANCET HAEMATOLOGY 2017; 4:e97-e98. [DOI: 10.1016/s2352-3026(17)30020-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 01/16/2017] [Indexed: 11/16/2022]
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42
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Jacobs LM, Wiernik PH, Dutcher JP, Muxi P. Long-Term Response and Possible Cure of Patients With B-Cell Malignancies With Dose-Escalated Rituximab. J Investig Med High Impact Case Rep 2017; 5:2324709617691307. [PMID: 28203581 PMCID: PMC5298442 DOI: 10.1177/2324709617691307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/04/2017] [Accepted: 01/08/2017] [Indexed: 11/17/2022] Open
Abstract
Rituximab (R), a chimeric monoclonal antibody targeting CD20 antigen on B-cells, has become a standard of care in the treatment of B-cell malignancies, most often in conjunction with cytotoxic chemotherapy. Activity has been demonstrated in many subtypes of B-cell lymphoma, including diffuse large cell lymphoma, follicular lymphoma (FL), mantle cell lymphoma (MCL), chronic lymphocytic leukemia (CLL), lymphocyte-predominant Hodgkin lymphoma, and Waldenström macroglobulinemia (WM). Additionally, dose escalation of R as a single agent has demonstrated improved activity in previously treated/poor prognosis CLL. We present 4 cases of B-cell malignancy (2 CLL variants/MCL, 1 FL, 1 WM) who received dose-escalated R as a single agent and achieved complete response (3 patients) and stable disease/partial response (1 patient) of 6.5+ to 15+ years duration. They have been off treatment for 6.5+ to 15+ years. Toxicity was minimal, with initial infusion reactions similar to those observed with standard dose infusions. There were no serious treatment-related adverse events or infections. Dose escalated R as a single agent may possibly be curative for some patients with B-cell malignancies, unlike the standard empiric dose of 375 mg/m2, and deserves further study.
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43
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Chaoui D, Choquet S, Sanhes L, Mahé B, Hacini M, Fitoussi O, Arkam Y, Orfeuvre H, Dilhuydy MS, Barry M, Jourdan E, Dreyfus B, Tempescul A, Leprêtre S, Bardet A, Leconte P, Maynadié M, Delmer A. Relapsed chronic lymphocytic leukemia retreated with rituximab: interim results of the PERLE study. Leuk Lymphoma 2017; 58:1366-1375. [DOI: 10.1080/10428194.2016.1243673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Driss Chaoui
- Hématologie, Centre hospitalier Victor Dupouy, Argenteuil, France
| | | | | | | | - Maya Hacini
- Hématologie, Centre hospitalier de Chambéry, Chambéry, France
| | | | - Yazid Arkam
- Hématologie, Hôpital Emile Muller, Mulhouse, France
| | - Hubert Orfeuvre
- Hématologie, Centre hospitalier de Fleyriat, Bourg en Bresse, France
| | | | - Marly Barry
- Hématologie, Centre hospitalier du Dr Duchenne, Boulogne sur Mer, France
| | | | | | | | | | - Aurélie Bardet
- Medical Affairs, Roche France, Boulogne-Billancourt, France
| | - Pierre Leconte
- Medical Affairs, Roche France, Boulogne-Billancourt, France
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Huber H, Edenhofer S, Estenfelder S, Stilgenbauer S. Profile of venetoclax and its potential in the context of treatment of relapsed or refractory chronic lymphocytic leukemia. Onco Targets Ther 2017; 10:645-656. [PMID: 28223822 PMCID: PMC5308588 DOI: 10.2147/ott.s102646] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Over the last few years, dramatic changes have occurred in the treatment of chronic lymphocytic leukemia (CLL). The current standard for young and fit patients with CLL remains chemoimmunotherapy, namely the fludarabine, cyclophosphamide, and rituximab (FCR) regimen. However, novel oral therapies are presently being introduced and represent a considerable breakthrough concerning effectiveness and safety profile. In particular, the very high-risk group of CLL patients, defined by the genetic aberration del(17p) and/or TP53 mutation, benefit from the new agents. These genetic abnormalities are the most relevant negative prognostic markers in the context of chemoimmunotherapy. New targeted therapies allow different approaches to improve outcomes.
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Affiliation(s)
- Henriette Huber
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Simone Edenhofer
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Sven Estenfelder
- Department of Internal Medicine III, Ulm University, Ulm, Germany
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45
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Mozas P, Delgado J. [Advances in the treatment of chronic lymphocytic leukaemia]. Med Clin (Barc) 2016; 147:447-454. [PMID: 27431885 DOI: 10.1016/j.medcli.2016.05.034] [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: 05/11/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 10/21/2022]
Abstract
Chronic lymphocytic leukemia (CLL), a proliferation of mature B cells, is one of the most prevalent haematological malignancies. Progress has been made in its treatment during the last few decades, and chemoimmunotherapy based on fludarabine, cyclophosphamide and rituximab is considered the treatment of choice for patients with standard-risk CLL and good performance status. However, due to the characterization of high-risk biological subgroups and its presentation in elderly patients and/or with comorbidities, targeted therapies, such as B-cell receptor inhibitors, have been developed and approved during the last few years. The current review examines traditional therapeutic strategies and focuses on new small molecules that already represent promising elements of the CLL treatment landscape.
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Affiliation(s)
- Pablo Mozas
- Servicio de Hematología, Instituto Clínico de Enfermedades Hemato-Oncológicas, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Julio Delgado
- Servicio de Hematología, Instituto Clínico de Enfermedades Hemato-Oncológicas, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España.
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46
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Jacobs RW, Awan FT, Leslie LA, Usmani SZ, Ghosh N. The shrinking role of chemotherapy in the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:1177-1187. [DOI: 10.1080/17474086.2016.1254545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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47
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Rossi D, Gerber B, Stüssi G. Predictive and prognostic biomarkers in the era of new targeted therapies for chronic lymphocytic leukemia. Leuk Lymphoma 2016; 58:1548-1560. [PMID: 27808579 DOI: 10.1080/10428194.2016.1250264] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Treatment options for chronic lymphocytic leukemia (CLL) have improved with the introduction of the B-cell receptor inhibitors ibrutinib and idelalisib, and of the BCL2 inhibitor venetoclax. While awaiting the results of head to head comparisons between novel agents and chemoimmunotherapy, predictive biomarkers can assist physicians in treatment tailoring. Though novel agents have modified the landscape of predictors at the time of treatment requirement, the usefulness of historical CLL prognostic biomarkers is still up-to-date when considering anticipation of time to first treatment. This review discusses: (i) disease-related (TP53 defects, immunoglobulin gene mutations), therapy-related (duration of remission), and patient-related (age, comorbidities) biomarkers that can be used in the clinical practice to inform CLL treatment decision either at the time of first line therapy and disease relapse; and (ii) the need of new biomarkers to re-define high-risk CLL because of the questioning by novel agents of historical prognostic factors.
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Affiliation(s)
- Davide Rossi
- a Hematology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland.,b Institute of Oncology Research , Bellinzona , Switzerland
| | - Bernhard Gerber
- a Hematology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
| | - Georg Stüssi
- a Hematology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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48
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Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. LANCET HAEMATOLOGY 2016; 3:e407-14. [DOI: 10.1016/s2352-3026(16)30064-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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49
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Zhang T, Cao L, Xie J, Shi N, Zhang Z, Luo Z, Yue D, Zhang Z, Wang L, Han W, Xu Z, Chen H, Zhang Y. Efficiency of CD19 chimeric antigen receptor-modified T cells for treatment of B cell malignancies in phase I clinical trials: a meta-analysis. Oncotarget 2016; 6:33961-71. [PMID: 26376680 PMCID: PMC4741817 DOI: 10.18632/oncotarget.5582] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/20/2015] [Indexed: 12/31/2022] Open
Abstract
Chimeric antigen receptor (CAR) modified T cells targeted CD19 showed promising clinical outcomes in treatment of B cell malignances such as chronic lymphocytic leukemia (CLL), acute lymphoblastic leukemia (ALL) and other indolent lymphomas. However, the clinical benefit varies tremendously among different trials. This meta-analysis investigated the efficacy (response rates and survival time) of CD19-CAR T cells in refractory B cell malignances in Phase I clinical trials. We searched publications between 1991 and 2014 from PubMed and Web of Science. Pooled response rates were calculated using random-effects models. Heterogeneity was investigated by subgroup analysis and meta-regression. Fourteen clinical trials including 119 patients were eligible for response rate evaluation, 62 patients in 12 clinical trials were eligible for progression-free survival analysis. The overall pooled response rate of CD19-CAR T cells was 73% (95% confidence interval [CI]: 46-94%). Significant heterogeneity across estimates of response rates was observed (p < 0.001, I2=88.3%). ALL patients have higher response rate (93%, 95% CI: 65-100%) than CLL (62%, 95% CI: 27-93%) and lymphoma patients (36%, 95% CI: 1-83%). Meta-regression analysis identified lymphodepletion and no IL-2 administrated T cells as two key factors associated with better clinical response. Lymphodepletion and higher infused CAR T cell number were associated with better prognosis. In conclusion, this meta-analysis showed a high clinical response rate of CD19-CAR T cell-based immunotherapy in treatment of refractory B cell malignancies. Lymphodepletion and increasing number of infused CD19-CAR T cells have positive correlations with the clinical efficiency, on the contrary, IL-2 administration to T cells is not recommended.
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Affiliation(s)
- Tengfei Zhang
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Hematology and Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ling Cao
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jing Xie
- Center for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Ni Shi
- Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio, USA
| | - Zhen Zhang
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zhenzhen Luo
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dongli Yue
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zimeng Zhang
- Department of Immunology, Harvard Medical School, Boston, Massachusetts, USA
| | - Liping Wang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Weidong Han
- Molecular & Immunological/Bio-Therapeutic Department, Institute of Basic Medicine, Chinese PLA General Hospital, Beijing, China
| | - Zhongwei Xu
- Department of Gastroenterology, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hu Chen
- Department of Hematopoietic Stem Cell Transplantation, Affiliated Hospital to Academy of Military Medical Science, Beijing, China
| | - Yi Zhang
- Biotherapy Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.,Engineering Key Laboratory for Cell Therapy of Henan Province, Zhengzhou, Henan, China.,School of Life Sciences, Zhengzhou University, Zhengzhou, Henan, China
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Montserrat E, Dreger P. Treatment of Chronic Lymphocytic Leukemia With del(17p)/TP53 Mutation: Allogeneic Hematopoietic Stem Cell Transplantation or BCR-Signaling Inhibitors? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16 Suppl:S74-81. [DOI: 10.1016/j.clml.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
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