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Skånland SS, Okkenhaug K, Davids MS. PI3K Inhibitors in Hematology: When One Door Closes…. Clin Cancer Res 2024; 30:3667-3675. [PMID: 38967552 PMCID: PMC11371526 DOI: 10.1158/1078-0432.ccr-24-0967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/25/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024]
Abstract
The PI3K signaling pathway regulates key cellular processes and is one of the most aberrantly activated pathways in cancer. The class I PI3K catalytic subunits p110γ and p110δ are highly enriched in leukocytes, providing an additional rationale for targeting these PI3Ks in hematologic malignancies. In 2014, the PI3Kδ inhibitor idelalisib was the first of four PI3K inhibitors (PI3Ki) to receive regulatory approval for relapsed B-cell malignancies. This was followed by approvals of the pan-class I inhibitor copanlisib (2017), the dual PI3Kγ/δ inhibitor duvelisib (2018), and the PI3Kδ and casein kinase 1ε inhibitor umbralisib (2021). Copanlisib and umbralisib received accelerated approvals, whereas idelalisib and duvelisib received initial accelerated approvals followed by full approvals. The accelerated approvals were based on overall response rates; however, follow-up studies showed increased risk of death and serious side effects. Furthermore, the confirmatory trial with copanlisib failed to show an improvement in progression-free survival when compared with chemoimmunotherapy. These developments led to black box warnings for idelalisib and duvelisib and withdrawal of copanlisib and umbralisib from the market by their manufacturers. Given the uncertain future of this drug class, additional manufacturers terminated ongoing phase III trials with novel PI3Kis. In this study, we review the development and current status of PI3Kis in hematology, limitations to their use, and our perspective on whether there is a future for PI3Kis in hematology.
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Affiliation(s)
- Sigrid S Skånland
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Klaus Okkenhaug
- Department of Pathology, University of Cambridge, Cambridge, United Kingdom
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Lou SY, Zheng FL, Tang YM, Zheng YN, Lu J, An H, Zhang EJ, Cui SL, Zhao HJ. TYM-3-98, a novel selective inhibitor of PI3Kδ, demonstrates promising preclinical antitumor activity in B-cell lymphomas. Life Sci 2024; 347:122662. [PMID: 38670450 DOI: 10.1016/j.lfs.2024.122662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
AIMS PI3Kδ is expressed predominately in leukocytes and is commonly found to be aberrantly activated in human B-cell lymphomas. Although PI3Kδ has been intensively targeted for discovering anti-lymphoma drugs, the application of currently approved PI3Kδ inhibitors has been limited due to unwanted systemic toxicities, thus warranting the development of novel PI3Kδ inhibitors with new scaffolds. MAIN METHODS We designed TYM-3-98, an indazole derivative, and evaluated its selectivity for all four PI3K isoforms, as well as its efficacy against various B-cell lymphomas both in vitro and in vivo. KEY FINDINGS We identified TYM-3-98 as a highly selective PI3Kδ inhibitor over other PI3K isoforms at both molecular and cellular levels. It showed superior antiproliferative activity in several B-lymphoma cell lines compared with the approved first-generation PI3Kδ inhibitor idelalisib. TYM-3-98 demonstrated a concentration-dependent PI3K/AKT/mTOR signaling blockage followed by apoptosis induction. In vivo, TYM-3-98 showed good pharmaceutical properties and remarkably reduced tumor growth in a human lymphoma xenograft model and a mouse lymphoma model. SIGNIFICANCE Our findings establish TYM-3-98 as a promising PI3Kδ inhibitor for the treatment of B-cell lymphoma.
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Affiliation(s)
- Si-Yue Lou
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China; Academy of Chinese Medical Sciences, Zhejiang Chinese Medical University, Binwen Rd, Hangzhou, Zhejiang 310053, China
| | - Fan-Li Zheng
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China; Department of Pharmacology, Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Yong-Mei Tang
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Ya-Nan Zheng
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China
| | - Jun Lu
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China
| | - Hai An
- Academy of Chinese Medical Sciences, Zhejiang Chinese Medical University, Binwen Rd, Hangzhou, Zhejiang 310053, China
| | - En-Jun Zhang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China
| | - Sun-Liang Cui
- Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China.
| | - Hua-Jun Zhao
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311403, China; Academy of Chinese Medical Sciences, Zhejiang Chinese Medical University, Binwen Rd, Hangzhou, Zhejiang 310053, China.
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DA Costa Machado AK, Machado CB, DE Pinho Pessoa FMC, Barreto IV, Gadelha RB, DE Sousa Oliveira D, Ribeiro RM, Lopes GS, DE Moraesfilho MO, DE Moraes MEA, Khayat AS, Moreira-Nunes CA. Development and Clinical Applications of PI3K/AKT/mTOR Pathway Inhibitors as a Therapeutic Option for Leukemias. CANCER DIAGNOSIS & PROGNOSIS 2024; 4:9-24. [PMID: 38173664 PMCID: PMC10758851 DOI: 10.21873/cdp.10279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/15/2023] [Indexed: 01/05/2024]
Abstract
Leukemias are hematological neoplasms characterized by dysregulations in several cellular signaling pathways, prominently including the PI3K/AKT/mTOR pathway. Since this pathway is associated with several important cellular mechanisms, such as proliferation, metabolism, survival, and cell death, its hyperactivation significantly contributes to the development of leukemias. In addition, it is a crucial prognostic factor, often correlated with therapeutic resistance. Changes in the PI3K/AKT/mTOR pathway are identified in more than 50% of cases of acute leukemia, especially in myeloid lineages. Furthermore, these changes are highly frequent in cases of chronic lymphocytic leukemia, especially those with a B cell phenotype, due to the correlation between the hyperactivation of B cell receptors and the abnormal activation of PI3Kδ. Thus, the search for new therapies that inhibit the activity of the PI3K/AKT/mTOR pathway has become the objective of several clinical studies that aim to replace conventional oncological treatments that have high rates of toxicities and low specificity with target-specific therapies offering improved patient quality of life. In this review we describe the PI3K/AKT/mTOR signal transduction pathway and its implications in leukemogenesis. Furthermore, we provide an overview of clinical trials that employed PI3K/AKT/mTOR inhibitors either as monotherapy or in combination with other cytotoxic agents for treating patients with various types of leukemias. The varying degrees of treatment efficacy are also reported.
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Affiliation(s)
- Anna Karolyna DA Costa Machado
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - Caio Bezerra Machado
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - Flávia Melo Cunha DE Pinho Pessoa
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - Igor Valentim Barreto
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - Renan Brito Gadelha
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | | | | | | | - Manoel Odorico DE Moraesfilho
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - Maria Elisabete Amaral DE Moraes
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
| | - André Salim Khayat
- Department of Biological Sciences, Oncology Research Center, Federal University of Pará, Belém, PA, Brazil
| | - Caroline Aquino Moreira-Nunes
- Department of Medicine, Pharmacogenetics Laboratory, Drug Research and Development Center (NPDM), Federal University of Ceará, Fortaleza, CE, Brazil
- Department of Biological Sciences, Oncology Research Center, Federal University of Pará, Belém, PA, Brazil
- Clementino Fraga Group, Central Unity, Molecular Biology Laboratory, Fortaleza, CE, Brazil
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Duchesneau ED, McNeill AM, Schary W, Pate V, Lund JL. Prognosis of older adults with chronic lymphocytic leukemia: A Surveillance, Epidemiology, and End Results-Medicare cohort study. J Geriatr Oncol 2023; 14:101602. [PMID: 37696241 DOI: 10.1016/j.jgo.2023.101602] [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: 11/14/2022] [Revised: 04/06/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION While prognosis for patients with chronic lymphocytic leukemia (CLL) has improved over time in younger adults, only modest improvements have occurred in older adults. We conducted a descriptive study of prognosis in older adults with CLL. MATERIALS AND METHODS We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2003 to 2016. We identified older adults (≥66 years) diagnosed with primary CLL between 2004 and 2015 (Overall Cohort). A subset who initiated CLL-directed therapy during the year following diagnosis was also identified (Treated Cohort). Both cohorts were matched to Medicare beneficiaries without cancer based on age, sex, and region. For each year from 2004 to 2013, three-year survival for patients with CLL and non-cancer comparators was described using Kaplan-Meier analysis. Inverse probability weighted Cox regression models were used to compare survival in the CLL and non-cancer comparator cohorts, accounting for demographic information and comorbidity and frailty indices. Among older adults with CLL, ten-year cause-specific cumulative mortality was estimated using Aalen-Johansen estimators that accounted for competing risks. Predictors of cause-specific mortality, including comorbidity and frailty burden, were assessed using sub-distribution hazards models. RESULTS In the Overall Cohort, three-year survival increased non-monotonically from 71.4% in 2004 to 73.4% in 2013, with a peak of 74.4% in 2011, and was lower than survival in non-cancer comparators (78.3% in 2004 to 83.2% in 2013). In the Treated Cohort, three-year survival was 56.3% in 2004 and 56.5% in 2013, with a peak of 64.2% in 2011. Cox models suggested that survival in the Treated Cohort was approaching survival in non-cancer comparators after 2011 (hazard ratio = 1.04, 95% confidence interval, 0.93-1.17). Ten-year cumulative mortality was 68.6% in the Overall Cohort and 81.7% in the Treated Cohort, with most deaths attributed to non-CLL causes. In the sub-distribution hazards models, age, year of diagnosis, frailty, and comorbidities were all associated with prognosis. DISCUSSION Prognosis in older adults has been stable over time and most patients with CLL die from non-CLL causes. CLL-directed treatment decision-making in older adults should consider age-related factors, such as comorbidity and frailty.
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Affiliation(s)
- Emilie D Duchesneau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America.
| | - Ann Marie McNeill
- AbbVie Inc., 1400 Sheridan Rd, North Chicago, IL, 60064, United States of America
| | - William Schary
- AbbVie Inc., 1400 Sheridan Rd, North Chicago, IL, 60064, United States of America
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America
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Owen C, Eisinga S, Banerji V, Johnson N, Gerrie AS, Aw A, Chen C, Robinson S. Canadian evidence-based guideline for treatment of relapsed/refractory chronic lymphocytic leukemia. Leuk Res 2023; 133:107372. [PMID: 37633157 DOI: 10.1016/j.leukres.2023.107372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
Following the recent publication of Canadian evidence-based guidelines for frontline treatment of chronic lymphocytic leukemia (CLL), the same group of clinicians developed guidelines for CLL in the relapsed/refractory (R/R) setting. The treatment of R/R CLL has changed significantly in the past few years, with many novel therapeutics available to hematologists across the country. These guidelines aim to standardize the management of CLL in the relapsed/refractory setting, using the best evidence currently available.
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Affiliation(s)
- Carolyn Owen
- Division of Hematology and Hematological Malignancies, Foothills Medical Centre, Calgary AB T2N 4N2, Canada.
| | | | - Versha Banerji
- Department of Hematology and Medical Oncology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Nathalie Johnson
- Department of Medicine, Jewish General Hospital, Montreal QC H3T 1E2, Canada
| | - Alina S Gerrie
- Division of Medical Oncology, Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC V5Z 4E6, Canada
| | - Andrew Aw
- Division of Hematology, The Ottawa Hospital, Ottawa, Ontario K1Y 4E9, Canada
| | - Christine Chen
- Department of Medical Oncology, University of Toronto, and Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | - Sue Robinson
- Division of Hematology, Dalhousie University, and GEII Health Sciences Centre, Halifax NS B3H 2Y9, Canada
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van der Straten L, Stege CAM, Kersting S, Nasserinejad K, Dubois J, Dobber JA, Mellink CHM, van der Kevie-Kersemaekers AMF, Evers LM, de Boer F, Koene HR, Schreurs J, van der Klift M, Velders GA, van der Spek E, van der Straaten HM, Hoogendoorn M, van Gelder M, Posthuma EFM, Visser HPJ, Houtenbos I, Idink CAM, Issa DE, Dompeling EC, van Zaanen HCT, Veelken JH, Levenga H, Tick LW, Terpstra WE, Tonino SH, Westerweel PE, Langerak AW, Kater AP, Levin MD. Fixed-duration venetoclax plus obinutuzumab improves quality of life and geriatric impairments in FCR-unfit patients with CLL. Blood 2023; 142:1131-1142. [PMID: 37363833 DOI: 10.1182/blood.2023020195] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/26/2023] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL)-related symptoms and morbidity related to the advanced age at diagnosis impairs the well-being of older adult patients. Therefore, it is essential to tailor treatment according to geriatric characteristics and aim for an improvement in health-related quality of life (HRQoL) as a primary treatment goal. In the HOVON139/GiVe trial, 12 cycles of fixed-duration venetoclax plus obinutuzumab (Ven-O) were shown to be effective and tolerable in FCR (fludarabine, cyclophosphamide, rituximab)-unfit patients with CLL (n = 67). However, prolonged venetoclax exposure as consolidation treatment led to increased toxicity with limited effect on minimal residual disease. To assess the impact of geriatric assessment on treatment outcomes and the patients' HRQoL, patient-reported outcomes (PROs), including function, depression, cognition, nutrition, physical performance, muscle parameters, comorbidities, and the European Organization for Research and Treatment of Cancer C30 and CLL17 questionnaires were assessed. At baseline, geriatric impairments were present in >90% of patients and ≥2 impairments present in 60% of patients predicted grade ≥3 nonhematological toxicity. During treatment, the number of geriatric impairments diminished significantly and clinically relevant improvements in HRQoL subscales were reached for global health status, physical functioning, role functioning, emotional functioning, fatigue, dyspnea, physical condition or fatigue, and worries or fears related to health and functioning. These improvements were comparable for patients receiving venetoclax consolidation and patients in whom treatment could mostly be discontinued. Collectively, frontline fixed-duration Ven-O improves overall PROs in older, unfit patients with CLL with and without geriatric impairments. This study was registered at EudraCT as 2015-004985-27 and the Netherlands Trial Register as NTR6043.
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Affiliation(s)
- Lina van der Straten
- Department of Immunology, Erasmus MC, Rotterdam, The Netherlands
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Claudia A M Stege
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam-Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Sabina Kersting
- Department of Hematology, HAGA Teaching Hospital, The Hague, The Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Julie Dubois
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Johan A Dobber
- Department of Laboratory Special Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Clemens H M Mellink
- Department of Human Genetics, Section Cytogenetics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Ludo M Evers
- Department of Laboratory Special Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fransien de Boer
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Harry R Koene
- Department of Hematology, Antonius Hospital, Nieuwegein, The Netherlands
| | - John Schreurs
- Department of Internal Medicine, Martini Hospital, Groningen, The Netherlands
| | | | - Gerjo A Velders
- Department of Internal Medicine, Gelderland Valley Hospital, Ede, The Netherlands
| | - Ellen van der Spek
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Mels Hoogendoorn
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Michel van Gelder
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Eduardus F M Posthuma
- Department of Internal Medicine, Reinier The Graaf Hospital, Delft, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein P J Visser
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Ilse Houtenbos
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Cecile A M Idink
- Department of Internal Medicine, ZorgSaam Hospital, Terneuzen, The Netherlands
| | - Djamila E Issa
- Department of Internal Medicine, Jeroen Bosch Hospital, s-Hertogenbosch, The Netherlands
| | | | - Henk C T van Zaanen
- Department of Internal Medicine, St Franciscus Hospital, Rotterdam, The Netherlands
| | - J Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henriette Levenga
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | - Lidwine W Tick
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, The Netherlands
| | - Wim E Terpstra
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Sanne H Tonino
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anton W Langerak
- Department of Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - Arnon P Kater
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Witkowska M, Majchrzak A, Robak P, Wolska-Washer A, Robak T. Metabolic and toxicological considerations for phosphoinositide 3-kinase delta inhibitors in the treatment of chronic lymphocytic leukemia. Expert Opin Drug Metab Toxicol 2023; 19:617-633. [PMID: 37714711 DOI: 10.1080/17425255.2023.2260305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/22/2023] [Accepted: 09/14/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Phosphoinositide 3-kinase delta (PI3Kδ) inhibitors are a class of novel agents that are mainly used to treat B-cell malignancies. They function by inhibiting one or more enzymes which are part of the PI3K/AKT/mTOR pathway. Idelalisib is a first-in-class PI3Kδ inhibitor effective in patients with B-cell lymphoid malignancies. AREAS COVERED This article reviews the chemical structure, mechanism of action, and metabolic and toxicological properties of PI3Kδ inhibitors and discusses their clinical applications in monotherapy and in combination with other agents for the treatment of chronic lymphocytic leukemia (CLL). A search was conducted of PubMed, Web of Science, and Google Scholar for articles in English. RESULTS/CONCLUSION PI3Kδ inhibitors hold potential for the treatment of B-cell malignancies, including CLL. However, their use is also associated with severe toxicities, including pneumonia, cytopenias, hepatitis, and rash. Newer drugs are in development to reduce toxicity with novel schedules and/or combinations. EXPERT OPINION The development of novel PI3Kδ inhibitors might help to reduce toxicity and improve efficacy in patients with CLL and other B-cell lymphoid malignancies.
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Affiliation(s)
- Magdalena Witkowska
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Agata Majchrzak
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
| | - Paweł Robak
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Anna Wolska-Washer
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Tadeusz Robak
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
- Department of Hematology, Medical University of Lodz, Lodz, Poland
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8
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Glaviano A, Foo ASC, Lam HY, Yap KCH, Jacot W, Jones RH, Eng H, Nair MG, Makvandi P, Geoerger B, Kulke MH, Baird RD, Prabhu JS, Carbone D, Pecoraro C, Teh DBL, Sethi G, Cavalieri V, Lin KH, Javidi-Sharifi NR, Toska E, Davids MS, Brown JR, Diana P, Stebbing J, Fruman DA, Kumar AP. PI3K/AKT/mTOR signaling transduction pathway and targeted therapies in cancer. Mol Cancer 2023; 22:138. [PMID: 37596643 PMCID: PMC10436543 DOI: 10.1186/s12943-023-01827-6] [Citation(s) in RCA: 196] [Impact Index Per Article: 196.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/18/2023] [Indexed: 08/20/2023] Open
Abstract
The PI3K/AKT/mTOR (PAM) signaling pathway is a highly conserved signal transduction network in eukaryotic cells that promotes cell survival, cell growth, and cell cycle progression. Growth factor signalling to transcription factors in the PAM axis is highly regulated by multiple cross-interactions with several other signaling pathways, and dysregulation of signal transduction can predispose to cancer development. The PAM axis is the most frequently activated signaling pathway in human cancer and is often implicated in resistance to anticancer therapies. Dysfunction of components of this pathway such as hyperactivity of PI3K, loss of function of PTEN, and gain-of-function of AKT, are notorious drivers of treatment resistance and disease progression in cancer. In this review we highlight the major dysregulations in the PAM signaling pathway in cancer, and discuss the results of PI3K, AKT and mTOR inhibitors as monotherapy and in co-administation with other antineoplastic agents in clinical trials as a strategy for overcoming treatment resistance. Finally, the major mechanisms of resistance to PAM signaling targeted therapies, including PAM signaling in immunology and immunotherapies are also discussed.
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Affiliation(s)
- Antonino Glaviano
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Aaron S C Foo
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
| | - Hiu Y Lam
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - Kenneth C H Yap
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - William Jacot
- Department of Medical Oncology, Institut du Cancer de Montpellier, Inserm U1194, Montpellier University, Montpellier, France
| | - Robert H Jones
- Cardiff University and Velindre Cancer Centre, Museum Avenue, Cardiff, CF10 3AX, UK
| | - Huiyan Eng
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Madhumathy G Nair
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Pooyan Makvandi
- The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Center, Inserm U1015, Université Paris-Saclay, Paris, France
| | - Matthew H Kulke
- Section of Hematology and Medical Oncology, Boston University and Boston Medical Center, Boston, MA, USA
| | - Richard D Baird
- Cancer Research UK Cambridge Centre, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jyothi S Prabhu
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Daniela Carbone
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Camilla Pecoraro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Daniel B L Teh
- Departments of Ophthalmology and Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, and Neurobiology Programme, National University of Singapore, Singapore, Singapore
| | - Gautam Sethi
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Vincenzo Cavalieri
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Kevin H Lin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Eneda Toska
- Department of Biochemistry and Molecular Biology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Matthew S Davids
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Patrizia Diana
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Justin Stebbing
- Division of Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - David A Fruman
- Department of Molecular Biology and Biochemistry, University of California, 216 Sprague Hall, Irvine, CA, USA
| | - Alan P Kumar
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
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9
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Gargiulo E, Teglgaard RS, Faitová T, Niemann CU. Immune Dysfunction and Infection - Interaction between CLL and Treatment: A Reflection on Current Treatment Paradigms and Unmet Needs. Acta Haematol 2023; 147:84-98. [PMID: 37497921 DOI: 10.1159/000533234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is a hematological malignancy characterized by immune dysfunction, which significantly contributes to increased morbidity and mortality due to infections. SUMMARY Advancement in therapeutic strategies based on combination chemoimmunotherapy and targeted treatment have increased life expectancy for patients affected by CLL. However, mortality and morbidity due to infection showed no improvement over the last decades. Although therapy options are highly efficient in targeting leukemic cells, several studies highlighted the interactions of different treatments with the tumor microenvironment immune components, significantly impacting their clinical efficacy and fostering increased risk of infections. KEY MESSAGES Given the profound immune dysfunction caused by CLL itself, treatment can thus represent a double-edged sword. Thus, it is essential to increase our understanding and awareness on how conventional therapies affect the disease-microenvironment-infection axis to ensure the best personalized strategy for each patient. This requires careful consideration of the advantages and disadvantages of efficient treatments, whether chemoimmunotherapy or targeted combinations, leading to risk of infectious complications. To this regard, our machine learning-based algorithm CLL Treatment-Infection Model, currently implemented into the local electronic health record system for Eastern Denmark, aims at early identification of patients at high risk of serious infections (PreVent-ACaLL; NCT03868722). We here review strategies for management of immune dysfunction and infections in CLL.
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Affiliation(s)
- Ernesto Gargiulo
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Infectious Diseases, PERSIMUNE, Rigshospitalet, Copenhagen, Denmark
| | | | - Tereza Faitová
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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10
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Shen R, Fu D, Dong L, Zhang MC, Shi Q, Shi ZY, Cheng S, Wang L, Xu PP, Zhao WL. Simplified algorithm for genetic subtyping in diffuse large B-cell lymphoma. Signal Transduct Target Ther 2023; 8:145. [PMID: 37032379 PMCID: PMC10083170 DOI: 10.1038/s41392-023-01358-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/11/2023] [Accepted: 01/31/2023] [Indexed: 04/11/2023] Open
Abstract
Genetic classification helps to disclose molecular heterogeneity and therapeutic implications in diffuse large B-cell lymphoma (DLBCL). Using whole exome/genome sequencing, RNA-sequencing, and fluorescence in situ hybridization in 337 newly diagnosed DLBCL patients, we established a simplified 38-gene algorithm (termed 'LymphPlex') based on the information on mutations of 35 genes and rearrangements of three genes (BCL2, BCL6, and MYC), identifying seven distinct genetic subtypes: TP53Mut (TP53 mutations), MCD-like (MYD88, CD79B, PIM1, MPEG1, BTG1, TBL1XR1, PRDM1, IRF4 mutations), BN2-like (BCL6 fusion, NOTCH2, CD70, DTX1, BTG2, TNFAIP3, CCND3 mutations), N1-like (NOTCH1 mutations), EZB-like (BCL2 fusion, EZH2, TNFRSF14, KMT2D, B2M, FAS, CREBBP, ARID1A, EP300, CIITA, STAT6, GNA13 mutations, with or without MYC rearrangement), and ST2-like (SGK1, TET2, SOCS1, DDX3X, ZFP36L1, DUSP2, STAT3, IRF8 mutations). Extended validation of 1001 DLBCL patients revealed clinical relevance and biological signature of each genetic subtype. TP53Mut subtype showed poor prognosis, characterized by p53 signaling dysregulation, immune deficiency, and PI3K activation. MCD-like subtype was associated with poor prognosis, activated B-cell (ABC) origin, BCL2/MYC double-expression, and NF-κB activation. BN2-like subtype showed favorable outcome within ABC-DLBCL and featured with NF-κB activation. N1-like and EZB-like subtypes were predominated by ABC-DLBCL and germinal center B-cell (GCB)-DLBCL, respectively. EZB-like-MYC+ subtype was characterized by an immunosuppressive tumor microenvironment, while EZB-like-MYC- subtype by NOTCH activation. ST2-like subtype showed favorable outcome within GCB-DLBCL and featured with stromal-1 modulation. Genetic subtype-guided targeted agents achieved encouraging clinical response when combined with immunochemotherapy. Collectively, LymphPlex provided high efficacy and feasibility, representing a step forward to the mechanism-based targeted therapy in DLBCL.
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Affiliation(s)
- Rong Shen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Di Fu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Dong
- Department of Pathology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mu-Chen Zhang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing Shi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zi-Yang Shi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu Cheng
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Pôle de Recherches Sino-Français en Science du Vivant et Génomique, Laboratory of Molecular Pathology, Shanghai, China
| | - Peng-Peng Xu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Wei-Li Zhao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics; National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Pôle de Recherches Sino-Français en Science du Vivant et Génomique, Laboratory of Molecular Pathology, Shanghai, China.
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11
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Iyer P, Wang L. Emerging Therapies in CLL in the Era of Precision Medicine. Cancers (Basel) 2023; 15:1583. [PMID: 36900373 PMCID: PMC10000606 DOI: 10.3390/cancers15051583] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Over the past decade, the treatment landscape of CLL has vastly changed from the conventional FC (fludarabine and cyclophosphamide) and FCR (FC with rituximab) chemotherapies to targeted therapies, including inhibitors of Bruton tyrosine kinase (BTK) and phosphatidylinositol 3-kinase (PI3K) as well as inhibitors of BCL2. These treatment options dramatically improved clinical outcomes; however, not all patients respond well to these therapies, especially high-risk patients. Clinical trials of immune checkpoint inhibitors (PD-1, CTLA4) and chimeric antigen receptor T (CAR T) or NK (CAR NK) cell treatment have shown some efficacy; still, long-term outcomes and safety issues have yet to be determined. CLL remains an incurable disease. Thus, there are unmet needs to discover new molecular pathways with targeted or combination therapies to cure the disease. Large-scale genome-wide whole-exome and whole-genome sequencing studies have discovered genetic alterations associated with disease progression, refined the prognostic markers in CLL, identified mutations underlying drug resistance, and pointed out critical targets to treat the disease. More recently, transcriptome and proteome landscape characterization further stratified the disease and revealed novel therapeutic targets in CLL. In this review, we briefly summarize the past and present available single or combination therapies, focusing on potential emerging therapies to address the unmet clinical needs in CLL.
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Affiliation(s)
- Prajish Iyer
- Department of Systems Biology, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Monrovia, CA 91007, USA
| | - Lili Wang
- Department of Systems Biology, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Monrovia, CA 91007, USA
- Toni Stephenson Lymphoma Center, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Duarte, CA 91016, USA
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12
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Simultaneous Inhibition of PI3Kgamma and PI3Kdelta Deteriorates T-cell Function With Implications for Chronic Lymphocytic Leukemia. Hemasphere 2023; 7:e840. [PMID: 36844182 PMCID: PMC9949793 DOI: 10.1097/hs9.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/03/2023] [Indexed: 02/24/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a common and incurable B-cell malignancy. Recent therapeutic approaches that target the B-cell receptor signaling pathway include inhibition of phosphatidylinositol-3-kinase (PI3K). The PI3K isoform delta is constitutively active in CLL, making it an attractive therapeutic target. However, the expression of PI3K isoforms is not exclusive to leukemic cells, as other immune cells in the tumor microenvironment also rely on PI3K activity. Subsequently, therapeutic inhibition of PI3K causes immune-related adverse events (irAEs). Here, we analyzed the impact of the clinically approved PI3Kδ inhibitors idelalisib and umbralisib, the PI3Kγ inhibitor eganelisib, and the dual-γ and -δ inhibitor duvelisib on the functional capacity of T cells. All investigated inhibitors reduced T-cell activation and proliferation in vitro, which is in line with PI3K being a crucial signaling component of the T-cell receptor signaling. Further, dual inhibition of PI3Kγ and PI3Kδ showed strong additive effects suggesting a role also for PI3Kγ in T cells. Extrapolation of this data to a clinical setting could provide an explanation for the observed irAEs in CLL patients undergoing treatment with PI3K inhibitors. Consequently, this highlights the need for a close monitoring of patients treated with PI3K inhibitors, and particularly duvelisib, due to their potentially increased risk of T-cell deficiencies and associated infections.
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13
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Smyth E, Eyre TA, Cheah CY. Emerging Therapies for the Management of Richter Transformation. J Clin Oncol 2023; 41:395-409. [PMID: 36130148 DOI: 10.1200/jco.22.01028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Richter transformation (RT) refers to the development of an aggressive lymphoma in patients with underlying chronic lymphocytic leukemia/small lymphocytic lymphoma. Aside from a small subgroup of patients with clonally unrelated and previously untreated chronic lymphocytic leukemia, the disease responds poorly to standard therapies and prognosis is dismal. Recent developments in the understanding of the biology of RT and the advent of several targeted agents may result in improved outcomes for these patients. The purpose of this review is to analyze recent data on the pathogenesis and treatment of RT. We reviewed studies addressing the pathophysiology of RT and analyzed the data for frontline chemoimmunotherapy and emerging targeted therapies likely to play a significant role in the future management of RT. Several biologic and clinical factors may help identify those who are unlikely to respond to conventional chemoimmunotherapy; where possible, these patients should be managed with a novel approach. Emerging therapies for the management of RT include chimeric antigen receptor T-cell therapy, noncovalent Bruton tyrosine kinase inhibitors, and T-cell-engaging bispecific antibodies. The use of less toxic and more effective targeted therapies may result in improved outcomes. Larger, prospective clinical trials are required to confirm efficacy and safety of novel agents for the management of RT, particularly when used in combination with other targeted therapies and in addition to chemoimmunotherapy regimens.
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Affiliation(s)
- Elizabeth Smyth
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Toby A Eyre
- Haematology and Cancer Centre, Oxford University Hospitals NHS Foundation Trust Oxford, Oxford, United Kingdom
| | - Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
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14
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Skånland SS, Brown JR. PI3K inhibitors in chronic lymphocytic leukemia: where do we go from here? Haematologica 2023; 108:9-21. [PMID: 35899388 PMCID: PMC9827175 DOI: 10.3324/haematol.2022.281266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Phosphatidylinositol 3-kinase (PI3K) inhibitors are effective in chronic lymphocytic leukemia (CLL). However, the severe toxicity profile associated with the first-generation inhibitors idelalisib and duvelisib, combined with the availability of other more tolerable agents, have limited their use. CLL is still considered incurable, and relapse after treatment, development of resistance, and treatment intolerance are common. It is therefore of interest to optimize the administration of currently approved PI3K inhibitors and to develop next-generation agents to improve tolerability, so that this class of agents will be considered an effective and safe treatment option when needed. These efforts are reflected in the large number of emerging clinical trials with PI3K inhibitors in CLL. Current strategies to overcome treatment limitations include intermittent dosing, which is established for copanlisib and zandelisib and under investigation for duvelisib and parsaclisib. A second strategy is to combine the PI3K inhibitor with another novel agent, either as a continuous regimen or a fixedduration regimen, to deepen responses. In addition to these approaches, it is of interest to identify higher-resolution actionable biomarkers that can predict treatment responses and toxicity, and inform personalized treatment decisions. Here, we discuss the current status of PI3K inhibitors in CLL, factors limiting the use of currently approved PI3K inhibitors in CLL, current strategies to overcome these limitations, and where to go next.
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Affiliation(s)
- Sigrid S Skånland
- Department of Cancer Immunology, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway; K. G. Jebsen Centre for B Cell Malignancies, Institute of Clinical Medicine, University of Oslo, Oslo.
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA
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15
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Izuegbuna OO. Polyphenols: Chemoprevention and therapeutic potentials in hematological malignancies. Front Nutr 2022; 9:1008893. [PMID: 36386899 PMCID: PMC9643866 DOI: 10.3389/fnut.2022.1008893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/02/2022] [Indexed: 01/25/2024] Open
Abstract
Polyphenols are one of the largest plant-derived natural product and they play an important role in plants' defense as well as in human health and disease. A number of them are pleiotropic molecules and have been shown to regulate signaling pathways, immune response and cell growth and proliferation which all play a role in cancer development. Hematological malignancies on the other hand, are cancers of the blood. While current therapies are efficacious, they are usually expensive and with unwanted side effects. Thus, the search for newer less toxic agents. Polyphenols have been reported to possess antineoplastic properties which include cell cycle arrest, and apoptosis via multiple mechanisms. They also have immunomodulatory activities where they enhance T cell activation and suppress regulatory T cells. They carry out these actions through such pathways as PI3K/Akt/mTOR and the kynurenine. They can also reverse cancer resistance to chemotherapy agents. In this review, i look at some of the molecular mechanism of action of polyphenols and their potential roles as therapeutic agents in hematological malignancies. Here i discuss their anti-proliferative and anti-neoplastic activities especially their abilities modulate signaling pathways as well as immune response in hematological malignancies. I also looked at clinical studies done mainly in the last 10-15 years on various polyphenol combination and how they enhance synergism. I recommend that further preclinical and clinical studies be carried out to ensure safety and efficacy before polyphenol therapies be officially moved to the clinics.
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Affiliation(s)
- Ogochukwu O. Izuegbuna
- Department of Haematology, Ladoke Akintola University of Technology (LAUTECH) Teaching Hospital, Ogbomoso, Nigeria
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16
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Ramos-Casals M, Flores-Chávez A, Brito-Zerón P, Lambotte O, Mariette X. Immune-related adverse events of cancer immunotherapies targeting kinases. Pharmacol Ther 2022; 237:108250. [DOI: 10.1016/j.pharmthera.2022.108250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
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17
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Pfister V, Marques FDM, Parra F, Yamamoto M, Gonçalves MV, Perobelli L, Buccheri V, Bandeira R, Fortier S, Azevedo A, Santucci R, Bellesso M, Fogliatto L, Ribeiro G, Lopes GS, Ikoma M, Figueiredo VP, Metze IGHL, Chiattone CS, Arrais‐Rodrigues C. Lower access to risk stratification tests and drugs, and worse survival of chronic lymphocytic leukaemia patients treated in public as compared to private hospitals in Brazil: A retrospective analysis of the Brazilian registry of chronic lymphocytic leukaemia. EJHAEM 2022; 3:698-706. [PMID: 36051063 PMCID: PMC9422035 DOI: 10.1002/jha2.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/22/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) has a highly variable clinical course. In addition to biological factors, socioeconomic factors and health system characteristics may influence CLL outcome. Data from the Brazilian Registry of CLL were analyzed to compare clinical and treatment-related characteristics in patients with CLL, from public or private institutions. A total of 3326 patients from 43 centres met the eligibility criteria, of whom 81% were followed up at public hospitals and 19% at private hospitals. The majority were male (57%), with a median age of 65 years. Comparing public and private hospitals, patients in public hospitals were older, had more advanced disease at diagnosis, and more frequently had elevated creatinine levels. All investigated prognostic markers were evaluated more often in private hospitals. First-line treatment was predominantly based on chlorambucil in 41% of the cases and fludarabine in 38%. Anti-CD20 monoclonal antibody was used in only 36% of cases. In public hospitals, significantly fewer patients received fludarabine-based regimens and anti-CD20 monoclonal antibodies. Patients from public hospitals had significantly worse overall survival (71% vs. 90% for private hospitals, p < 0.0001) and treatment-free survival (32% vs. 40%, for private hospitals, p < 0.0001) at seven years. Our data indicate striking differences between patients followed in public and private hospitals in Brazil. A worse clinical condition and lack of accessibility to basic laboratory tests and adequate therapies may explain the worse outcomes of patients treated in public institutions.
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Affiliation(s)
- Verena Pfister
- Escola Paulista de Medicina /Universidade Federal de São Paulo, UNIFESPSão PauloBrazil
- Brazilian Registry of CLL – Associação Brasileira de Hematologia e HemoterapiaHemoterapiaBrazil
| | - Fernanda de Morais Marques
- Escola Paulista de Medicina /Universidade Federal de São Paulo, UNIFESPSão PauloBrazil
- Brazilian Registry of CLL – Associação Brasileira de Hematologia e HemoterapiaHemoterapiaBrazil
- Hospital BrigadeiroSão PauloBrazil
| | - Flavia Parra
- Brazilian Registry of CLL – Associação Brasileira de Hematologia e HemoterapiaHemoterapiaBrazil
| | - Mihoko Yamamoto
- Escola Paulista de Medicina /Universidade Federal de São Paulo, UNIFESPSão PauloBrazil
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Celso Arrais‐Rodrigues
- Escola Paulista de Medicina /Universidade Federal de São Paulo, UNIFESPSão PauloBrazil
- Brazilian Registry of CLL – Associação Brasileira de Hematologia e HemoterapiaHemoterapiaBrazil
- Hospital 9 de JulhoSão PauloBrazil
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18
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Frustaci AM, Deodato M, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. SOHO State of the Art Updates and Next Questions: What is Fitness in the Era of Targeted Agents? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:356-361. [PMID: 34969641 DOI: 10.1016/j.clml.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 06/14/2023]
Abstract
The importance of coexisting conditions in chronic lymphocytic leukemia (CLL) outcome has been increasingly recognized over the past years. The role of comorbidities to predict patients' vulnerability toward immunochemotherapy has been well establish, especially since some of the tools commonly used to evaluate patients' fitness were employed to determine treatment eligibility in randomized trials. Nevertheless, is it still unclear how much fitness weights on treatment outcome with targeted agents and which assessment should be preferred. There are key differences in the toxicity profile between novel agents that are getting much more evident in retrospective, real-life experiences, rather than clinical trials. Therefore, an individual patient's comorbid medical conditions may be a deciding factor in therapy selection. Here, we analyze main evidence in literature on the predicting value of comorbidity assessment on outcome and management of CLL patients receiving novel agents.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy.
| | - Marina Deodato
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Giulia Zamprogna
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Roberto Cairoli
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Marco Montillo
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
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19
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Condoluci A, Rossi D. Biology and Treatment of Richter Transformation. Front Oncol 2022; 12:829983. [PMID: 35392219 PMCID: PMC8980468 DOI: 10.3389/fonc.2022.829983] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/25/2022] [Indexed: 12/28/2022] Open
Abstract
Richter transformation (RT), defined as the development of an aggressive lymphoma on a background of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), represents a clinical unmet need because of its dismal prognosis. An increasing body of knowledge in the field of RT is arising from the recent development of preclinical models depicting the biology underlying this aggressive disease. Consistently, new therapeutic strategies based on a genetic rationale are exploring actionable pathogenic pathways to improve the outcome of patients in this setting. In this review, we summarize the current understandings on RT biology and the available treatment options.
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Affiliation(s)
- Adalgisa Condoluci
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
| | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
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20
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Gadi D, Griffith A, Wang Z, Tyekucheva S, Rai V, Fernandes SM, Machado JH, Munugalavadla V, Lederer J, Brown JR. Idelalisib reduces regulatory T cells and activates T helper 17 cell differentiation in relapsed refractory patients with chronic lymphocytic leukaemia. Br J Haematol 2022; 197:207-211. [PMID: 35170759 PMCID: PMC9263710 DOI: 10.1111/bjh.18053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 12/13/2022]
Abstract
Phosphatidylinositol 3 kinase (PI3K) inhibitors such as idelalisib have been associated with potentially severe autoimmune toxicity. In the present study, we demonstrate that relapsed refractory patients with chronic lymphocytic leukaemia treated with idelalisib rituximab on the phase III registration trial show uniform decrease in regulatory T cells (Tregs) and increase in CD8 T cells with treatment. Patients who do not develop toxicity show enrichment for T cells expressing multiple chemokine receptors, while those who do develop toxicity have an activated CD8 T cell population with T helper 17 cell differentiation at baseline, which then increases, leading to an increased CD8:Treg ratio that likely triggers autoimmune toxicity.
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Affiliation(s)
- Deepti Gadi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alec Griffith
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Zixu Wang
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Vanessa Rai
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stacey M Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - John-Hanson Machado
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | | | - James Lederer
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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21
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Hus I, Puła B, Robak T. PI3K Inhibitors for the Treatment of Chronic Lymphocytic Leukemia: Current Status and Future Perspectives. Cancers (Basel) 2022; 14:1571. [PMID: 35326722 PMCID: PMC8945984 DOI: 10.3390/cancers14061571] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 12/04/2022] Open
Abstract
Phosphoinositide 3-kinases (PI3Ks) signaling regulates key cellular processes, such as growth, survival and apoptosis. Among the three classes of PI3K, class I is the most important for the development, differentiation and activation of B and T cells. Four isoforms are distinguished within class I (PI3Kα, PI3Kβ, PI3Kδ and PI3Kγ). PI3Kδ expression is limited mainly to the B cells and their precursors, and blocking PI3K has been found to promote apoptosis of chronic lymphocytic leukemia (CLL) cells. Idelalisib, a selective PI3Kδ inhibitor, was the first-in-class PI3Ki introduced into CLL treatment. It showed efficacy in patients with del(17p)/TP53 mutation, unmutated IGHV status and refractory/relapsed disease. However, its side effects, such as autoimmune-mediated pneumonitis and colitis, infections and skin changes, limited its widespread use. The dual PI3Kδ/γ inhibitor duvelisib is approved for use in CLL patients but with similar toxicities to idelalisib. Umbralisib, a highly selective inhibitor of PI3Kδ and casein kinase-1ε (CK1ε), was found to be efficient and safe in monotherapy and in combination regimens in phase 3 trials in patients with CLL. Novel PI3Kis are under evaluation in early phase clinical trials. In this paper we present the mechanism of action, efficacy and toxicities of PI3Ki approved in the treatment of CLL and developed in clinical trials.
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Affiliation(s)
- Iwona Hus
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (I.H.); (B.P.)
| | - Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (I.H.); (B.P.)
| | - Tadeusz Robak
- Copernicus Memorial Hospital, 93-510 Lodz, Poland
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
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22
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Harris V, Borlagdan J, Muluneh B. Oral oncolytic treatment for chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:935-944. [PMID: 35084245 DOI: 10.1177/10781552211073906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this article is to review the current supporting literature for the use of oral oncolytics in chronic lymphocytic leukemia, consideration for their use and management of adverse drug events that may limit use. DATA SOURCES NCCN guidelines were utilized to determine available oral options for treatment of chronic lymphocytic leukemia. A literature review was carried out through PubMed to find relevant clinical trials that evaluated the efficacy and safety of Bruton's tyrosine kinase inhibitors, BCL-2 inhibitors and PI3K-δ inhibitors. Medication package inserts and primary literature regarding toxicity were used to determine appropriate adverse drug event management. DATA SUMMARY A total of 7 clinical trials were found for the evaluation the efficacy and safety of burton tyrosine kinase inhibitor, 1 clinical trial for the BCL-1 inhibitor venetoclax and 4 trials were for PI3K-δ inhibitors. The data from these studies suggest that ibrutinib can be used first line in previously untreated patients and relapsed/refractory patients as well as acalabrutinib. The data also support the use of venetoclax, idelalisib, and duvelisib in relapsed/refractory chronic lymphocytic leukemia patients. CONCLUSIONS The use of oral-only oncolytics could be a viable option for reducing the risk of infection due to limiting exposure to healthcare settings. Current literature suggests oral oncolytics may be an option, but there are several considerations to evaluate including medication adherence, drug-drug interactions, adverse events, and financial toxicity.
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Affiliation(s)
- Vincent Harris
- Pharmacy, 427363Novant Health Presbyterian Medical Centre, 200 Hawthorne Ln, Charlotte, NC, USA 28204
| | | | - Benyam Muluneh
- 15521UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
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van der Straten L, Hengeveld PJ, Kater AP, Langerak AW, Levin MD. Treatment Approaches to Chronic Lymphocytic Leukemia With High-Risk Molecular Features. Front Oncol 2021; 11:780085. [PMID: 34956898 PMCID: PMC8695615 DOI: 10.3389/fonc.2021.780085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/23/2021] [Indexed: 12/30/2022] Open
Abstract
The clinical course of chronic lymphocytic leukemia (CLL) is highly variable. Over the past decades, several cytogenetic, immunogenetic and molecular features have emerged that identify patients suffering from CLL with high-risk molecular features. These biomarkers can clearly aid prognostication, but may also be capable of predicting the efficacy of various treatment strategies in subgroups of patients. In this narrative review, we discuss treatment approaches to CLL with high-risk molecular features. Specifically, we review and provide a comprehensive overview of clinical trials evaluating the efficacy of chemotherapy, chemoimmunotherapy and novel agent-based treatments in CLL patients with TP53 aberrations, deletion of the long arm of chromosome 11, complex karyotype, unmutated IGHV, B cell receptor stereotypy, and mutations in NOTCH1 or BIRC3. Furthermore, we discuss future pharmaceutical and immunotherapeutic perspectives for CLL with high-risk molecular features, focusing on agents currently under investigation in clinical trials.
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Affiliation(s)
- Lina van der Straten
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Netherlands.,Laboratory Medical Immunology, Department of Immunology, Erasmus MC, Rotterdam, Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, Netherlands
| | - Paul J Hengeveld
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Netherlands.,Laboratory Medical Immunology, Department of Immunology, Erasmus MC, Rotterdam, Netherlands
| | - Arnon P Kater
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, Netherlands
| | - Anton W Langerak
- Laboratory Medical Immunology, Department of Immunology, Erasmus MC, Rotterdam, Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Netherlands
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24
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De Novellis D, Cacace F, Caprioli V, Wierda WG, Mahadeo KM, Tambaro FP. The TKI Era in Chronic Leukemias. Pharmaceutics 2021; 13:2201. [PMID: 34959482 PMCID: PMC8709313 DOI: 10.3390/pharmaceutics13122201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022] Open
Abstract
Tyrosine kinases are proteins involved in physiological cell functions including proliferation, differentiation, and survival. However, the dysregulation of tyrosine kinase pathways occurs in malignancy, including hematological leukemias such as chronic myeloid leukemia (CML) and chronic lymphocytic leukemia (CLL). Particularly, the fusion oncoprotein BCR-ABL1 in CML and the B-cell receptor (BCR) signaling pathway in CLL are critical for leukemogenesis. Therapeutic management of these two hematological conditions was fundamentally changed in recent years, making the role of conventional chemotherapy nearly obsolete. The first, second, and third generation inhibitors (imatinib, dasatinib, nilotinib, bosutinib, and ponatinib) of BCR-ABL1 and the allosteric inhibitor asciminib showed deep genetic and molecular remission rates in CML, leading to the evaluation of treatment discontinuation in prospective trials. The irreversible BTK inhibitors (ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and spebrutinib) covalently bind to the C481 amino acid of BTK. The reversible BTK inhibitor pirtobrutinib has a different binding site, overcoming resistance associated with mutations at C481. The PI3K inhibitors (idelalisib and duvelisib) are also effective in CLL but are currently less used because of their toxicity profiles. These tyrosine kinase inhibitors are well-tolerated, do have some associated in-class side effects that are manageable, and have remarkably improved outcomes for patients with hematologic malignancies.
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Affiliation(s)
- Danilo De Novellis
- Hematology and Transplant Center, University “Hospital San Giovanni di Dio e Ruggi D’Aragona”, 84131 Salerno, Italy
| | - Fabiana Cacace
- Unità Operativa di Trapianto di Cellule Staminali Ematopoietiche e Terapie Cellulari, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, 80123 Napoli, Italy; (F.C.); (V.C.); (F.P.T.)
| | - Valeria Caprioli
- Unità Operativa di Trapianto di Cellule Staminali Ematopoietiche e Terapie Cellulari, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, 80123 Napoli, Italy; (F.C.); (V.C.); (F.P.T.)
| | - William G. Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Kris M. Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy, CARTOX Program, University of Texas at MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Francesco Paolo Tambaro
- Unità Operativa di Trapianto di Cellule Staminali Ematopoietiche e Terapie Cellulari, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, 80123 Napoli, Italy; (F.C.); (V.C.); (F.P.T.)
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25
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Phase 2 study of obinutuzumab (GA-101), ibrutinib and venetoclax (CLL2-GIVe) in patients with untreated high-risk chronic lymphocytic leukemia. Blood 2021; 139:1318-1329. [PMID: 35108374 DOI: 10.1182/blood.2021013208] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
Despite considerable treatment advances with targeted therapies for patients with chronic lymphocytic leukemia (CLL) deemed high-risk (del(17p) and/or TP53 mutation), outcome is still inferior compared to other CLL patients. Combining multiple agents with distinct mechanisms of action may further improve outcomes. CLL2-GIVe is an open-label, multicenter trial, which enrolled patients with previously untreated CLL with del(17p) and/or TP53 mutation. Patients received induction therapy with obinutuzumab (GA-101), ibrutinib and venetoclax (GIVe) for cycles 1-6 and consolidation therapy with venetoclax and ibrutinib for cycles 7-12. Ibrutinib monotherapy was continued for cycles 13-36 in patients not reaching a complete response (CR) with serial undetectable minimal residual disease (uMRD) after consolidation. The primary endpoint was CR rate at cycle 15 (final restaging). Secondary endpoints included MRD, survival and safety. All 41 patients, enrolled between September 2016 and August 2018, received study treatment and were included in efficacy and safety populations. With a CR rate of 58.5% at cycle 15, the primary endpoint was met (95% CI: 42.1-73.7; p<0.001). At final restaging, 78.0% of patients had uMRD in peripheral blood; 65.9% of patients had uMRD in bone marrow. Estimated progression-free and overall survival rates at 24 months were both 95.1%. Adverse events were reported in all patients, most were low grade (grade ≥3: 23.9%). Two deaths were reported (cardiac failure and ovarian carcinoma), neither related to study treatment. The CLL2-GIVe treatment regimen has a manageable safety profile and is a first-line treatment of good efficacy for patients with high-risk CLL.
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Tarantelli C, Argnani L, Zinzani PL, Bertoni F. PI3Kδ Inhibitors as Immunomodulatory Agents for the Treatment of Lymphoma Patients. Cancers (Basel) 2021; 13:5535. [PMID: 34771694 PMCID: PMC8582887 DOI: 10.3390/cancers13215535] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/23/2021] [Accepted: 10/29/2021] [Indexed: 12/20/2022] Open
Abstract
The development of small molecules able to block specific or multiple isoforms of phosphoinositide 3-kinases (PI3K) has already been an active field of research for many years in the cancer field. PI3Kδ inhibitors are among the targeted agents most extensively studied for the treatment of lymphoma patients and PI3Kδ inhibitors are already approved by regulatory agencies. More recently, it became clear that the anti-tumor activity of PI3K inhibitors might not be due only to a direct effect on the cancer cells but it can also be mediated via inhibition of the kinases in non-neoplastic cells present in the tumor microenvironment. T-cells represent an important component of the tumor microenvironment and they comprise different subpopulations that can have both anti- and pro-tumor effects. In this review article, we discuss the effects that PI3Kδ inhibitors exert on the immune system with a particular focus on the T-cell compartment.
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Affiliation(s)
- Chiara Tarantelli
- Institute of Oncology Research, Faculty of Biomedical Sciences, USI, 6500 Bellinzona, Switzerland;
| | - Lisa Argnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.A.); (P.L.Z.)
- Istituto di Ematologia “Seràgnoli”, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi di Bologna, 40138 Bologna, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.A.); (P.L.Z.)
- Istituto di Ematologia “Seràgnoli”, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università degli Studi di Bologna, 40138 Bologna, Italy
| | - Francesco Bertoni
- Institute of Oncology Research, Faculty of Biomedical Sciences, USI, 6500 Bellinzona, Switzerland;
- Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
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Abstract
PURPOSE OF REVIEW The treatment landscape of chronic lymphocytic leukaemia (CLL) has tremendously evolved in the last decades, from chemo to chemoimmunotherapy (CIT) and, eventually, to pathway inhibitors that target critical pathways for leukaemic cells survival. Also, treatment goals are moving towards achieving undetectable minimal residual disease with little toxicity. RECENT FINDINGS We performed a thorough review of the history of treatment approvals by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA). This review especially focuses on therapies that are currently approved by both agencies. The indications and particular characteristics of each drug are examined. SUMMARY Currently available treatment approaches for CLL offer the opportunity to individualize therapy for every single patient with CLL. Inhibitors of B-cell receptor (BCR) signalling pathways and antiapoptotic proteins are nowadays the treatment of choice for most CLL patients, but CIT can be an option for younger and fit patients with low-risk disease [mutated IGHV, no del(11q) or del(17p)/TP53 mutations].
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28
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Treatment Options for Elderly/Unfit Patients with Chronic Lymphocytic Leukemia in the Era of Targeted Drugs: A Comprehensive Review. J Clin Med 2021; 10:jcm10215104. [PMID: 34768624 PMCID: PMC8584288 DOI: 10.3390/jcm10215104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) incidence increases with age reaching 37.9/100,000 in patients over 85 years. Although there is no standardized geriatric tool specifically validated for CLL, a correct framing of the fitness status is of critical importance to individualize treatment strategies. Based on the evidence available to date, frontline chemoimmunotherapy has an increasingly narrowing application, being eligible for candidacy only in elderly fit patients without or with minimal geriatric syndromes. On the other hand, treatment with BCR inhibitors, monotherapy, or in combination with anti-CD20 antibodies (e.g., obinutuzumab), must be preferred both for frontline and relapsed CLL not only in unfit patients, but also in fit patients with unmutated IGHV or harboring del(17p) and/or TP53 mutations/deletions. Second-generation inhibitors (e.g., acalabrutinib, zanubrutinib, pirtobrutinib) are novel compounds that, due to their better safety profile and different specificity, will help physicians overcome some of the safety issues and treatment resistances. In the era of targeted therapies, treatment decisions in elderly and/or unfit patients with CLL must be a balance between efficacy and safety, carefully evaluating comorbidities and geriatric syndromes to ensure the best approach to improve both quality of life and life expectancy.
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29
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Allegra A, Tonacci A, Musolino C, Pioggia G, Gangemi S. Secondary Immunodeficiency in Hematological Malignancies: Focus on Multiple Myeloma and Chronic Lymphocytic Leukemia. Front Immunol 2021; 12:738915. [PMID: 34759921 PMCID: PMC8573331 DOI: 10.3389/fimmu.2021.738915] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/29/2021] [Indexed: 12/19/2022] Open
Abstract
Secondary immunodeficiency is reported in most patients with hematological malignancies such as chronic lymphocytic leukemia and multiple myeloma. The aim of our review was to evaluate the existing literature data on patients with hematological malignancies, with regard to the effect of immunodeficiency on the outcome, the clinical and therapeutic approach, and on the onset of noninfectious complications, including thrombosis, pleural effusion, and orofacial complications. Immunodeficiency in these patients has an intense impact on their risk of infection, in turn increasing morbidity and mortality even years after treatment completion. However, these patients with increased risk of severe infectious diseases could be treated with adequate vaccination coverage, but the vaccines' administration can be associated with a decreased immune response and an augmented risk of adverse reactions. Probably, immunogenicity of the inactivated is analogous to that of healthy subjects at the moment of vaccination, but it undertakes a gradual weakening over time. However, the dispensation of live attenuated viral vaccines is controversial because of the risk of the activation of vaccine viruses. A particular immunization schedule should be employed according to the clinical and immunological condition of each of these patients to guarantee a constant immune response without any risks to the patients' health.
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MESH Headings
- Animals
- Humans
- Immunocompromised Host
- Immunogenicity, Vaccine
- Immunologic Deficiency Syndromes/epidemiology
- Immunologic Deficiency Syndromes/immunology
- Immunologic Deficiency Syndromes/therapy
- Incidence
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Multiple Myeloma/epidemiology
- Multiple Myeloma/immunology
- Multiple Myeloma/therapy
- Opportunistic Infections/epidemiology
- Opportunistic Infections/immunology
- Opportunistic Infections/prevention & control
- Risk Factors
- Vaccination
- Vaccine Efficacy
- Vaccines/administration & dosage
- Vaccines/adverse effects
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Messina, Italy
| | - Alessandro Tonacci
- Clinical Physiology Institute, National Research Council of Italy (IFC-CNR), Pisa, Italy
| | - Caterina Musolino
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, Messina, Italy
| | - Giovanni Pioggia
- Institute for Biomedical Research and Innovation (IRIB), National Research Council of Italy (CNR), Messina, Italy
| | - Sebastiano Gangemi
- School of Allergy and Clinical Immunology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Richter Transformation in Chronic Lymphocytic Leukemia: Update in the Era of Novel Agents. Cancers (Basel) 2021; 13:cancers13205141. [PMID: 34680290 PMCID: PMC8533993 DOI: 10.3390/cancers13205141] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 01/09/2023] Open
Abstract
Richter transformation (RT) is a poorly understood complication of chronic lymphocytic leukemia (CLL) with a dismal prognosis. It is associated with a switch in histopathology and biology, generally with a transformation of the original CLL clone to diffuse large B-cell lymphoma (DLBCL) or less frequently to Hodgkin's variant of Richter transformation (HVRT). It occurs in 2-10% of CLL patients, with an incidence rate of 0.5-1% per year, and may develop in treatment-naïve patients, although it is more common following therapy. In recent years, there has been a deeper understanding of the molecular pathogenesis of RT that involves the inactivation of the TP53 tumor suppressor gene in 50-60% of cases and the activation of aberrations of NOTCH1 and MYC pathways in about 30% of cases. Compared to the preceding CLL, 80% of cases with DLBCL-RT and 30% of HVRT harbor the same IGHV-D-J rearrangements, indicating a clonal evolution of the disease, while the remaining cases represent de novo lymphomas that are clonally unrelated. Despite advances in understanding the molecular variations and the pathogenesis of the disease, there is still no significant improvement in patient outcomes. However, if no clinical trials were designed for patients with RT in the past, now there many studies for these patients that incorporate new drugs and novel combinations that are being explored. In this review, we summarize the new information accumulated on RT with special emphasis on results involving the novel therapy tested for this entity, which represents an unmet clinical need.
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Svanberg R, Janum S, Patten PEM, Ramsay AG, Niemann CU. Targeting the tumor microenvironment in chronic lymphocytic leukemia. Haematologica 2021; 106:2312-2324. [PMID: 33882636 PMCID: PMC8409023 DOI: 10.3324/haematol.2020.268037] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
The tumor microenvironment (TME) plays an essential role in the development, growth, and survival of the malignant B-cell clone in chronic lymphocytic leukemia (CLL). Within the proliferation niches of lymph nodes, bone marrow, and secondary lymphoid organs, a variety of phenotypically and functionally altered cell types, including T cells, natural killer cells, monocytes/macrophages, endothelial and mesenchymal stroma cells, provide crucial survival signals, along with CLL-cellinduced suppression of antitumor immune responses. The B-cell receptor pathway plays a pivotal role in mediating the interaction between CLL cells and the TME. However, an increasing number of additional components of the multifactorial TME are being discovered. Although the majority of therapeutic strategies employed in CLL hitherto have focused on targeting the leukemic cells, emerging evidence implies that modulation of microenvironmental cells and CLL-TME interactions by novel therapeutic agents significantly affect their clinical efficacy. Thus, improving our understanding of CLL-TME interactions and how they are affected by current therapeutic agents may improve and guide treatment strategies. Identification of novel TME interactions may also pave the road for the development of novel therapeutic strategies targeting the TME. In this review, we summarize current evidence on the effects of therapeutic agents on cells and interactions within the TME. With a growing demand for improved and personalized treatment options in CLL, this review aims at inspiring future exploration of smart drug combination strategies, translational studies, and novel therapeutic targets in clinical trials.
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Affiliation(s)
| | - Sine Janum
- Department of Clinical Haemato-oncology, Bartholomew's Hospital, Barts Health Trust, London
| | - Piers E M Patten
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London
| | - Alan G Ramsay
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London
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Tam CS, Robak T, Ghia P, Kahl BS, Walker P, Janowski W, Simpson D, Shadman M, Ganly PS, Laurenti L, Opat S, Tani M, Ciepluch H, Verner E, Šimkovič M, Österborg A, Trněný M, Tedeschi A, Paik JC, Kuwahara SB, Feng S, Ramakrishnan V, Cohen A, Huang J, Hillmen P, Brown JR. Zanubrutinib monotherapy for patients with treatment naïve chronic lymphocytic leukemia and 17p deletion. Haematologica 2021; 106:2354-2363. [PMID: 33054121 PMCID: PMC8409041 DOI: 10.3324/haematol.2020.259432] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/17/2020] [Indexed: 12/27/2022] Open
Abstract
Patients with chronic lymphocytic leukemia or small lymphocytic lymphoma whose tumors carry deletion of chromosome 17p13.1 [del(17p)] have an unfavorable prognosis and respond poorly to standard chemoimmunotherapy. Zanubrutinib is a selective next-generation Bruton tyrosine kinase inhibitor. We evaluated the safety and efficacy of zanubrutinib 160 mg twice daily in treatment-naïve patients with del(17p) disease enrolled in a dedicated, nonrandomized cohort (Arm C) of the phase 3 SEQUOIA trial. A total of 109 patients (median age, 70 years; range, 42 - 86) with centrally confirmed del(17p) were enrolled and treated. After a median of 18.2 months (range, 5.0 - 26.3), seven patients had discontinued study treatment due to progressive disease, four due to an adverse event, and one due to withdrawal of consent. The overall response rate was 94.5% with 3.7% of patients achieving complete response with or without incomplete hematologic recovery. The estimated 18-month progression-free survival rate was 88.6% (95% CI, 79.0 - 94.0) and the estimated 18-month overall survival rate was 95.1% (95% CI, 88.4 - 98.0). Most common all-grade adverse events included contusion (20.2%), upper respiratory tract infection (19.3%), neutropenia/neutrophil count decreased (17.4%), and diarrhea (16.5%). Grade ≥ 3 adverse events were reported in 53 patients (48.6%), most commonly neutropenia (12.9%) and pneumonia (3.7%). An adverse event of atrial fibrillation was reported in three patients (2.8%). Zanubrutinib was active and well tolerated in this large, prospectively enrolled treatment cohort of previously untreated patients with del(17p) chronic lymphocytic leukemia/small lymphocytic lymphoma. This trial was registered at ClinicalTrials.gov as #NCT03336333.
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Affiliation(s)
- Constantine S Tam
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia; Royal Melbourne Hospital, Parkville, Victoria, Australia; St Vincent's Hospital Melbourne, Fitzroy, Victoria.
| | | | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milano
| | - Brad S Kahl
- Washington University School of Medicine, St Louis, MO
| | | | | | | | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA
| | - Peter S Ganly
- Department of Haematology, Christchurch Hospital, Christchurch
| | - Luca Laurenti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Stephen Opat
- Monash Health, Clayton, Victoria, Australia; Monash University, Clayton, Victoria
| | - Monica Tani
- Hematology Unit, Santa Maria delle Croci Hospital, Ravenna
| | | | - Emma Verner
- Concord Repatriation General Hospital, Concord, NSW, Australia; University of Sydney, Concord, NSW
| | - Martin Šimkovič
- Fourth Department of Internal Medicine - Hematology, University Hospital, Hradec Kralove, Czech Republic; Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Anders Österborg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden; Department of Hematology, Karolinska University Hospital, Stockholm
| | - Marek Trněný
- First Department of Medicine, First Faculty of Medicine, Charles University, General Hospital, Prague, Czech Republic
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Crombie JL, Brown JR. The future of antibody therapy in chronic lymphocytic leukemia. Expert Opin Emerg Drugs 2021; 26:323-336. [PMID: 34375544 DOI: 10.1080/14728214.2021.1966414] [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] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Outcomes in chronic lymphocytic leukemia (CLL) have been dramatically improved with the addition of anti-CD20 antibodies to chemotherapy, defining a new standard of care for many years. More recently, therapies targeting fundamental signaling and anti-apoptotic pathways within the CLL cell have demonstrated dramatic clinical responses, including in patients with high-risk prognostic markers, thus emerging as preferred therapy for many patients. While the addition of anti-CD20 antibodies to traditional chemotherapy resulted in significant improvements in outcomes, the role of monoclonal antibodies in the era of targeted agents remains an active area of investigation. Furthermore, since the advent of next-generation anti-CD20 antibodies, the role of specific anti-CD20 antibodies remains an open question. AREAS COVERED In this review, we highlight the important role that anti-CD20 antibody therapy has had in the field of CLL, both when used with chemotherapy and in combination with targeted therapy, as well as the current studies that are further exploring this treatment paradigm in the modern era. EXPERT OPINION While anti-CD20 antibodies have played a pivotal role in the treatment of CLL, additional studies will be required to determine the optimal application of these therapies in combination with targeted therapy.
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Affiliation(s)
- Jennifer L Crombie
- Department of Medical Oncology , Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology , Dana-Farber Cancer Institute, Boston, MA, USA
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Abstract
ABSTRACT In this article, we carry out an overview on the management options available for chronic lymphocytic leukemia (CLL) patients and discuss possible treatment decisions, taking into account the issue of sustainability and availability. Targeted agents have shown to be superior compared with chemoimmunotherapy (CIT) in terms of progression-free survival in high-risk CLL. In the majority of studies, however, continuous treatment was compared with fixed-duration CIT and no overall survival or progression-free survival-2 (time from randomization to second progression or death) advantage could be documented. Meanwhile, a substantial financial burden on both patients and payers has raised issues about affordability and adherence to treatment. Therefore, value-based pricing of new drugs has been used to set up price negotiation policies in several countries, and fixed-duration therapy has shown to be less costly than continuous treatment. Thus, CIT continues to have a role in the treatment of CLL patients with a favorable genetic profile, that is, with a mutated IGHV gene profile and a wild-type TP53. Targeted treatment represents the preferred choice in patients with an unmutated IGHV gene configuration and/or a TP53 disruption, provided that adherence to treatment is guaranteed and bearing in mind that should costly drugs not be available for frontline treatment, new agents can be very effective as first salvage treatment.
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Eyre TA, Preston G, Kagdi H, Islam A, Nicholson T, Smith HW, Cursley AP, Ramroth H, Xing G, Gu L, Rajakumaraswamy N, Fegan C. A retrospective observational study to evaluate the clinical outcomes and routine management of patients with chronic lymphocytic leukaemia treated with idelalisib and rituximab in the UK and Ireland (RETRO-idel). Br J Haematol 2021; 194:69-77. [PMID: 34121184 PMCID: PMC8361941 DOI: 10.1111/bjh.17475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 02/28/2021] [Indexed: 01/10/2023]
Abstract
Idelalisib (IDL) is an oral first‐in‐class phosphatidylinositol 3‐kinase delta (PI3Kδ) inhibitor approved for chronic lymphocytic leukaemia (CLL) alongside rituximab (R) since 2014. However, little data exist on routine practice. The RETRO‐idel was a protocol‐led, retrospective study of 110 patients [n = 27 front‐line (1L)] who received IDL‐R. The primary end‐point was clinical overall response rate (ORR). The median (range) follow‐up of the whole cohort was 30·2 (0·1–51·9) months. The median (range) age was 72 (48–89) years. Tumour protein p53‐disruption was common [100% 1L, 32·5% relapsed/refractory (R/R)]. The best ORR (intention‐to‐treat) was 88·2% (1L 96·3%, R/R 85·5%). Overall, the median event‐free survival (mEFS) was 20·3 months and time‐to‐next treatment was 29·2 months. The mEFS for 1L patients was 18·7 months and R/R patients was 21·7 months. The 3‐year overall survival was 56·1% (95% confidence interval 45·7–65·3). IDL was discontinued in 87·3% (n = 96). More patients discontinued due to adverse events in the front‐line setting (1L 63·0% vs. R/R 44·6%) and due to progressive disease in R/R patients (20·5% vs. 3·7% in 1L). Lower respiratory tract infection/pneumonia were reported in 34·5% (Grade ≥3, 19·1%), diarrhoea in 30·9% (Grade ≥3, 6·4%), and colitis in 9·1% (Grade ≥3, 5·5%). Overall, these data describe clear efficacy for IDL‐R in routine practice. No new safety signals were identified, although careful management of known toxicities is required.
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Affiliation(s)
- Toby A Eyre
- Haematology, Oxford University NHS Trust, Oxford, UK
| | | | - Huseini Kagdi
- Department of Haematology, London North West Healthcare NHS Trust, Harrow, UK
| | - Amin Islam
- Haematology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Toby Nicholson
- Department of Haematology, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Harry W Smith
- Medical Affairs, Gilead Sciences Europe Ltd, London, UK
| | - Adam P Cursley
- Clinical Operations, Gilead Sciences Europe Ltd, Uxbridge, UK
| | | | - Guan Xing
- Gilead Sciences Inc, Foster City, USA
| | - Lin Gu
- Biostatistics, Gilead Sciences Inc, Foster City, USA
| | | | - Christopher Fegan
- Department of Haematology, University Hospital of Wales, Cardiff, UK
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Fried LJ, Criscito MC, Stevenson ML, Pomeranz MK. Chronic lymphocytic leukemia and the skin: implications for the dermatologist. Int J Dermatol 2021; 61:519-531. [PMID: 33951189 DOI: 10.1111/ijd.15629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/09/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022]
Abstract
B-cell chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in the United States, and its diagnosis can have many dermatologic implications. For one, the cutaneous manifestations of CLL include several entities, most notably leukemia cutis, eosinophilic dermatosis of hematologic malignancy, and a heightened risk of skin infections. Additionally, CLL patients are at an increased risk of secondary malignancies, most commonly of the skin. Furthermore, a number of commonly utilized treatments for CLL have cutaneous implications which should be considered in the interdisciplinary management of CLL patients. In this review, we will provide an update on the diverse cutaneous manifestations of CLL and CLL-directed therapies in order to help guide dermatologic management of this increasingly prevalent patient population.
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Affiliation(s)
- Lauren J Fried
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York City, NY, USA
| | - Maressa C Criscito
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York City, NY, USA
| | - Mary L Stevenson
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York City, NY, USA
| | - Miriam K Pomeranz
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York City, NY, USA
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Cardiovascular toxicity of PI3Kα inhibitors. Clin Sci (Lond) 2021; 134:2595-2622. [PMID: 33063821 DOI: 10.1042/cs20200302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/27/2020] [Accepted: 09/30/2020] [Indexed: 02/07/2023]
Abstract
The phosphoinositide 3-kinases (PI3Ks) are a family of intracellular lipid kinases that phosphorylate the 3'-hydroxyl group of inositol membrane lipids, resulting in the production of phosphatidylinositol 3,4,5-trisphosphate from phosphatidylinositol 4,5-bisphosphate. This results in downstream effects, including cell growth, proliferation, and migration. The heart expresses three PI3K class I enzyme isoforms (α, β, and γ), and these enzymes play a role in cardiac cellular survival, myocardial hypertrophy, myocardial contractility, excitation, and mechanotransduction. The PI3K pathway is associated with various disease processes but is particularly important to human cancers since many gain-of-function mutations in this pathway occur in various cancers. Despite the development, testing, and regulatory approval of PI3K inhibitors in recent years, there are still significant challenges when creating and utilizing these drugs, including concerns of adverse effects on the heart. There is a growing body of evidence from preclinical studies revealing that PI3Ks play a crucial cardioprotective role, and thus inhibition of this pathway could lead to cardiac dysfunction, electrical remodeling, vascular damage, and ultimately, cardiovascular disease. This review will focus on PI3Kα, including the mechanisms underlying the adverse cardiovascular effects resulting from PI3Kα inhibition and the potential clinical implications of treating patients with these drugs, such as increased arrhythmia burden, biventricular cardiac dysfunction, and impaired recovery from cardiotoxicity. Recommendations for future directions for preclinical and clinical work are made, highlighting the possible role of PI3Kα inhibition in the progression of cancer-related cachexia and female sex and pre-existing comorbidities as independent risk factors for cardiac abnormalities after cancer treatment.
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Guarente V, Sportoletti P. Lessons, Challenges and Future Therapeutic Opportunities for PI3K Inhibition in CLL. Cancers (Basel) 2021; 13:cancers13061280. [PMID: 33805745 PMCID: PMC7999552 DOI: 10.3390/cancers13061280] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 01/04/2023] Open
Abstract
Simple Summary The phosphoinositide 3-kinase (PI3K) is a family of kinases that play a key role in the biology of chronic lymphocytic leukemia (CLL). Inhibitors of PI3K demonstrated efficacy in the treatment of CLL, associated with significant adverse events that limited the clinical use of this drugs. In this review, we underlined the relevance of PI3K inhibitors in CLL, we collected recent data about the use of these molecules in clinical practice and in clinical trial discussing strategies for the management of adverse events, which could help to improve the use of these therapies in the treatment of CLL. Abstract Chronic lymphocytic leukemia (CLL) shows constitutive phosphatidylinositol 3-kinase (PI3K) activation resulting from aberrant regulation of the B-cell receptor (BCR) signaling. PI3K inhibitors have been evaluated in CLL therapy, bringing a new treatment opportunity for patients with this disease. Despite the proven therapeutic efficacy, the use of approved PI3K inhibitors is limited by severe immune-mediated toxicities and given the availability of other more tolerable agents. This article reviews the relevance of PI3K signaling and pharmacologic inhibition in CLL. Data on efficacy and toxicity of PI3K inhibitors are also presented, as well as strategies for overcoming barriers for their clinical use in CLL treatment.
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Petrackova A, Turcsanyi P, Papajik T, Kriegova E. Revisiting Richter transformation in the era of novel CLL agents. Blood Rev 2021; 49:100824. [PMID: 33775465 DOI: 10.1016/j.blre.2021.100824] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/14/2021] [Accepted: 02/19/2021] [Indexed: 12/18/2022]
Abstract
Richter transformation (RT) is the development of aggressive lymphoma - most frequently diffuse large B-cell lymphoma (DLBCL) and rarely Hodgkin lymphoma (HL) - arising on the background of chronic lymphocytic leukaemia (CLL). Despite recent advances in CLL treatment, RT also develops in patients on novel agents, usually occurring as an early event. RT incidence is lower in CLL patients treated with novel agents in the front line compared to relapsed/refractory cases, with a higher incidence in patients with TP53 disruption. The genetic heterogeneity and complexity are higher in RT-DLBCL than CLL; the genetics of RT-HL are largely unknown. In addition to TP53, aberrations in CDKN2A, MYC, and NOTCH1 are common in RT-DLBCL; however, no distinct RT-specific genetic aberration is recognised yet. RT-DLBCL on ibrutinib is frequently associated with BTK and PLCG2 mutations. Here, we update on genetic analysis, diagnostics and treatment options in RT in the era of novel agents.
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Affiliation(s)
- Anna Petrackova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Peter Turcsanyi
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Tomas Papajik
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic.
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Stefaniuk P, Onyszczuk J, Szymczyk A, Podhorecka M. Therapeutic Options for Patients with TP53 Deficient Chronic Lymphocytic Leukemia: Narrative Review. Cancer Manag Res 2021; 13:1459-1476. [PMID: 33603488 PMCID: PMC7886107 DOI: 10.2147/cmar.s283903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/20/2020] [Indexed: 01/03/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL), which is the most common type of leukemia in western countries in adults, is characterized by heterogeneity in clinical course, prognosis and response to the treatment. Although, in recent years a number of factors with probable prognostic value in CLL have been identified (eg NOTCH1, SF3B1 and BIRC-3 mutations, or evaluation of microRNA expression), TP53 aberrations are still the most important single factors of poor prognosis. It was found that approximately 30% of all TP53 defects are mutations lacking 17p13 deletion, whereas sole 17p13 deletion with the absence of TP53 mutation consists of 10% of all TP53 defects. The detection of del(17)(p13) and/or TP53 mutation is not a criterion itself for starting antileukemic therapy, but it is associated with an aggressive course of the disease and poor response to the standard chemoimmunotherapy. Treatment of patients with CLL harbouring TP53-deficiency requires drugs that promote cell death independently of TP53. Novel and smarter therapies revolutionize the treatment of del(17p) and/or aberrant TP53 CLL, but development of alternative therapeutic approaches still remains an issue of critical importance.
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Affiliation(s)
- Paulina Stefaniuk
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Julia Onyszczuk
- Students Scientific Association, Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Szymczyk
- Department of Clinical Transplantology, Medical University of Lublin, Lublin, Poland
| | - Monika Podhorecka
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
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Lumish M, Falchi L, Imber BS, Scordo M, von Keudell G, Joffe E. How we treat mature B-cell neoplasms (indolent B-cell lymphomas). J Hematol Oncol 2021; 14:5. [PMID: 33407745 PMCID: PMC7789477 DOI: 10.1186/s13045-020-01018-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022] Open
Abstract
Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.
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Affiliation(s)
- Melissa Lumish
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Lorenzo Falchi
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Brandon S Imber
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Michael Scordo
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Gottfried von Keudell
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Erel Joffe
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA.
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Lee JC, Lamanna N. Is There a Role for Chemotherapy in the Era of Targeted Therapies? Curr Hematol Malig Rep 2020; 15:72-82. [PMID: 32107713 DOI: 10.1007/s11899-020-00563-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW The treatment landscape of chronic lymphocytic leukemia has been rapidly evolving over the past few years. The prior standard of care, chemoimmunotherapy, is being replaced by targeted agents, and the utility of chemotherapy has come under question. In this review, we examine recent data comparing chemoimmunotherapy to targeted agents, how these data impact clinical management, and whether there are potential future roles for cytotoxic chemotherapy. RECENT FINDINGS Clinical trials have shown improved clinical outcomes with targeted agents compared to traditional chemoimmunotherapy. Based on these data, the current treatment paradigm primarily favors targeted agents over chemoimmunotherapy, with a few exceptions. However, targeted agents have notable limitations, and thus, there may be a future role of cytotoxic chemotherapy when administered in combination with targeted agents. Although targeted agents have nearly replaced chemoimmunotherapy in the treatment of chronic lymphocytic leukemia, novel combinations utilizing chemotherapy are being developed that may lead to better outcomes.
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Affiliation(s)
| | - Nicole Lamanna
- Columbia University Medical Center, NY, USA. .,Associate Attending, Leukemia Service, Director of the Chronic Lymphocytic Leukemia Program, Hematologic Malignancies Section, Herbert Irving Comprehensive Cancer Center, New York-Presbyterian/Columbia University Medical Center, NY, USA.
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Hanlon A, Brander DM. Managing toxicities of phosphatidylinositol-3-kinase (PI3K) inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:346-356. [PMID: 33275709 PMCID: PMC7727518 DOI: 10.1182/hematology.2020000119] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Despite the proven effective approach to targeting the phosphatidylinositol-3-kinase (PI3K) pathway in B-cell malignancies, the approved PI3K inhibitors idelalisib and duvelisib have been less commonly selected for patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), given the availability of other more tolerable agents. However, patients with CLL/SLL can experience a disease course that is multiply relapsed, refractory, or intolerant to treatment, and PI3K inhibitors can achieve meaningful responses. This article reviews the common early- and late-onset (considered immune-mediated) toxicities with PI3K inhibitors, including infections, hepatotoxicity, diarrhea and/or colitis, and pneumonitis. Data on pretreatment considerations, toxicity management, and drug rechallenge are presented. In addition, next-generation PI3K inhibitors and novel treatment approaches with PI3K inhibitors, including combinations, time-limited treatments, and intermittent dosing, are highlighted.
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Cavallini C, Galasso M, Pozza ED, Chignola R, Lovato O, Dando I, Romanelli MG, Krampera M, Pizzolo G, Donadelli M, Scupoli MT. Effects of CD20 antibodies and kinase inhibitors on B-cell receptor signalling and survival of chronic lymphocytic leukaemia cells. Br J Haematol 2020; 192:333-342. [PMID: 33216963 DOI: 10.1111/bjh.17139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 09/09/2020] [Indexed: 01/12/2023]
Abstract
Recently, clinical trial results have established inhibitors of B-cell receptor (BCR)-associated kinase (BAKi), with or without CD20 moniclonal antibodies (mAbs), as the preferred first-line treatment for most chronic lymphocytic leukaemia (CLL) patients. Using phosphospecific flow cytometry, we showed that in leukaemic cells from CLL patients the CD20 therapeutic antibodies - rituximab, ofatumumab, and obinutuzumab - inhibited BCR signalling pathways targeting preferentially pBTKY551 - but not BTKY223 - and pAKT. On the contrary, ibrutinib and idelalisib reduced pBTKY223 to a higher extent than pBTKY551 . The strong reduction of pAKT induced by idelalisib was enhanced by its combination with rituximab or ofatumumab. Moreover, CD20 mAbs and BAKi induced the death of leukaemia cells that was significantly potentiated by their combination. Analysis of the enhancement of cell death in these combinations revealed an approximately additive enhancement induced by rituximab or obinutuzumab combined with ibrutinib or idelalisib. Taken together, our data identified negative regulatory effects of CD20 mAbs and their combinations with BAKi on BCR signalling and cell survival in CLL. In conclusion, this study advances our understanding of mechanisms of action of CD20 mAbs as single agents or in combination with BAKi and could inform on the potential of combined therapies in ongoing and future clinical trials in patients with CLL.
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Affiliation(s)
- Chiara Cavallini
- Research Center LURM (Interdepartmental Laboratory of Medical Research), University of Verona, Verona, Italy
| | - Marilisa Galasso
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Elisa Dalla Pozza
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Roberto Chignola
- Department of Biotechnology, University of Verona, Verona, Italy
| | - Ornella Lovato
- Research Center LURM (Interdepartmental Laboratory of Medical Research), University of Verona, Verona, Italy
| | - Ilaria Dando
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria G Romanelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Giovanni Pizzolo
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Massimo Donadelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Maria T Scupoli
- Research Center LURM (Interdepartmental Laboratory of Medical Research), University of Verona, Verona, Italy.,Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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Rodgers TD, Williams AM, Baran A, Reagan PM, Casulo C, Zent CS, Evans A, Friedberg JW, Barr PM. Toxicity patterns of novel PI3K combinations in patients with non-Hodgkin lymphoma. Leuk Lymphoma 2020; 62:598-605. [PMID: 33100068 DOI: 10.1080/10428194.2020.1837796] [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] [Indexed: 10/23/2022]
Abstract
Phosphoinositide-3-kinase (PI3K) inhibitors have efficacy in lymphoid malignancies; however, inflammatory and infectious toxicities can compromise the treatment course. An improved understanding of these toxicities will guide clinical use and further development. We evaluated the occurrence of treatment-related adverse events (AEs) in a retrospective review of 79 patients treated in standard fashion with PI3K inhibitor monotherapy or with anti-CD20 monoclonal antibodies or as part of a novel combination regimen. Patients treated with a novel combination were at a higher risk of developing a severe AE compared to those treated with standard therapy (HR 1.89, 95% CI 1.02, 3.49; p = .04). Additionally, previously untreated patients were at higher risk of developing a severe AE compared to previously treated patients (HR 3.19, 95% CI 1.48, 6.84; p = .003). These results caution against the use of untested PI3K inhibitor combinations in routine practice and suggest that early phase clinical trials should utilize conservative treatment schemas.
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Affiliation(s)
- Thomas D Rodgers
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - AnnaLynn M Williams
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrea Baran
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Patrick M Reagan
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Carla Casulo
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Clive S Zent
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Andrew Evans
- Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jonathan W Friedberg
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Paul M Barr
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
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Marchesini G, Nadali G, Facchinelli D, Candoni A, Cattaneo C, Laurenti L, Fanci R, Farina F, Lessi F, Visentin A, Marchesi F, Prezioso L, Spolzino A, Tisi MC, Trastulli F, Picardi M, Verga L, Dargenio M, Busca A, Pagano L. Infections in patients with lymphoproliferative diseases treated with targeted agents: SEIFEM multicentric retrospective study. Br J Haematol 2020; 193:316-324. [PMID: 33058237 PMCID: PMC8246914 DOI: 10.1111/bjh.17145] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 12/24/2022]
Abstract
We describe the opportunistic infections occurring in 362 patients with lymphoproliferative disorders treated with ibrutinib and idelalisib in clinical practice. Overall, 108 of 362 patients (29·8%) developed infections, for a total of 152 events. Clinically defined infections (CDI) were 49·3% (75/152) and microbiologically defined infections (MDI) were 50·7% (77/152). Among 250 patients treated with ibrutinib, 28·8% (72/250) experienced one or more infections, for a total of 104 episodes. MDI were 49% (51/104). Bacterial infections were 66·7% (34/51), viral 19·6% (10/51) and invasive fungal diseases (IFD) 13·7% (7/51). Among the 112 patients treated with idelalisib, 32·1% (36/112) experienced one or more infections, for a total of 48 episodes. MDI were 54·2% (26/48). Bacterial infections were 34·6% (9/26), viral 61·5% (16/26) and IFD 3·8% (1/26). With ibrutinib, the rate of bacterial infections was significantly higher compared to idelalisib (66·7% vs. 34·6%; P = 0·007), while viral infections were most frequent in idelalisib (61·5% vs. 19·6%; P < 0·001). Although a higher rate of IFD was observed in patients treated with ibrutinib, the difference was not statistically significant (13·7% vs. 3·8% respectively; P = 0·18). Bacteria are the most frequent infections with ibrutinib, while viruses are most frequently involved with idelalisib.
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Affiliation(s)
- Gessica Marchesini
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Gianpaolo Nadali
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Davide Facchinelli
- Hematology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | - Anna Candoni
- Division of Hematology and Stem Cell Transplantation, University Hospital of Udine, Udine, Italy
| | | | - Luca Laurenti
- Institute of Hematology, Fondazione Policlinico A. Gemelli - IRCCS -Università Cattolica S. Cuore, Roma, Italy
| | - Rosa Fanci
- Haematology Unit, Careggi Hospital and University of Firenze, Italy
| | - Francesca Farina
- Division of Hematology and Stem Cell Transplantation, IRCCS San Raffaele, Milano, Italy
| | - Federica Lessi
- Division of Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | - Andrea Visentin
- Division of Hematology and Clinical Immunology, University of Padova, Padova, Italy
| | - Francesco Marchesi
- Hematology and Stem Cell Transplantation Unit, Regina Elena National Cancer Institute, Roma, Italy
| | - Lucia Prezioso
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angelica Spolzino
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Fabio Trastulli
- Department of Clinical Medicine and Surgery, Federico II University Medical School, Napoli, Italy
| | - Marika Picardi
- Institute of Hematology, Fondazione Policlinico A. Gemelli - IRCCS -Università Cattolica S. Cuore, Roma, Italy
| | - Luisa Verga
- Hematology and CTA ASST Monza, Milano Bicocca University, Ospedale San Gerardo, Monza, Italy
| | - Michelina Dargenio
- Hematology and Stem Cell Transplantation Unit, Vito Fazzi' Hospital, Lecce, Italy
| | - Alessandro Busca
- SSD Division of Hematology and Stem Cell Transplantation, A.O.U. Citta' della Salute, Torino, Italy
| | - Livio Pagano
- Institute of Hematology, Fondazione Policlinico A. Gemelli - IRCCS -Università Cattolica S. Cuore, Roma, Italy
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47
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Visentin A, Frezzato F, Severin F, Imbergamo S, Pravato S, Romano Gargarella L, Manni S, Pizzo S, Ruggieri E, Facco M, Brunati AM, Semenzato G, Piazza F, Trentin L. Lights and Shade of Next-Generation Pi3k Inhibitors in Chronic Lymphocytic Leukemia. Onco Targets Ther 2020; 13:9679-9688. [PMID: 33061448 PMCID: PMC7532889 DOI: 10.2147/ott.s268899] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/03/2020] [Indexed: 12/12/2022] Open
Abstract
The treatment (i.e. therapy and management) of chronic lymphocytic leukemia (i.e. the disease) has been improved thanks to the introduction (i.e. approval) of kinase inhibitors during the last years. PI3K is one of the most important kinases at the crossroad to the B-cell receptor and cytokine receptor which play a key role in CLL cell survival, proliferation and migration. Idelalisib is the first in class PI3Kδ inhibitor approved for the treatment of relapsed/refractory CLL in combination with rituximab. Idelalisib activity in heavily treated patients is balanced by recurrent adverse events which limit its long-term use. These limitations prompt the investigation on novel PI3K inhibitors, also targeting different protein isoforms, and alternative schedule strategies. In this regard, duvelisib is the only PI3K γ and δ inhibitor approved as single agent for relapsed CLL. In this review, we will address novel insights on PI3K structure, isoforms, regulating signaling and the most updated data of next-generation PI3K inhibitors in CLL.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Federica Frezzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Filippo Severin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Silvia Imbergamo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Leila Romano Gargarella
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Sabrina Manni
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Serena Pizzo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Edoardo Ruggieri
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Monica Facco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | | | - Gianpietro Semenzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy.,Veneto Institute of Molecular Medicine, Padua, Italy
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48
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Tedeschi A. What is Fitness in the Era of Targeted Agents? CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2020; 20 Suppl 1:S84-S86. [DOI: 10.1016/s2152-2650(20)30472-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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49
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Harkins RA, Patel SP, Flowers CR. Cost-effectiveness of New Targeted Agents in the Treatment of Chronic Lymphocytic Leukemia. Cancer J 2020; 25:418-427. [PMID: 31764123 PMCID: PMC7141587 DOI: 10.1097/ppo.0000000000000411] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common adult leukemia and is clinically heterogeneous. Integration of oral targeted therapies (OTTs) in the management of CLL has fundamentally altered CLL treatment pathways and improved outcomes for patients with CLL.We review the cost-effectiveness of OTTs in the treatment of CLL. We used MeSH (Medical Subject Heading) terms and keywords to search the National Library of Medicine online MEDLINE database (PubMed) for articles related to cost-effectiveness of OTTs in CLL care.Oral targeted therapies add considerable expense to the treatment of CLL for patients and the health care system. Cost-effectiveness analyses of OTTs are not uniform in their conclusions and depend on patient groups selected for analysis. Given the substantial increase in expense associated with integration of OTTs in CLL treatment, cost reduction methods are needed to ensure equitable access to novel therapies for all patients with CLL.
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MESH Headings
- Clinical Decision-Making
- Combined Modality Therapy
- Cost-Benefit Analysis
- Critical Pathways
- Disease Management
- Disease Susceptibility
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Molecular Targeted Therapy/economics
- Molecular Targeted Therapy/methods
- Practice Guidelines as Topic
- Treatment Outcome
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50
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Abstract
Inhibitors of PI3Kδ hold great potential for the therapy of chronic lymphocytic leukemia and B-cell malignancies. After initially exciting efficacy results with idelalisib, the first-in-class inhibitor, the emergence of unexpected and unpredictable autoimmune toxicities, worse in less heavily treated and younger patients, has decreased the use of the currently available inhibitors. Newer drugs in development are attempting to reduce toxicity with novel schedules and/or combinations. This article reviews the clinical data on efficacy and toxicity across the class and discusses ongoing efforts to understand and mitigate the likely on-target autoimmune toxicity.
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MESH Headings
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- B-Lymphocytes/drug effects
- B-Lymphocytes/immunology
- B-Lymphocytes/metabolism
- B-Lymphocytes/pathology
- Class I Phosphatidylinositol 3-Kinases/antagonists & inhibitors
- Class I Phosphatidylinositol 3-Kinases/genetics
- Class I Phosphatidylinositol 3-Kinases/metabolism
- Clinical Trials as Topic
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Phosphoinositide-3 Kinase Inhibitors/pharmacology
- Phosphoinositide-3 Kinase Inhibitors/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Jennifer R Brown
- From Harvard Medical School and CLL Center, Dana-Farber Cancer Institute, Boston, MA
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