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Lopedote P, Kittai AS, Danilov A. Utilizing risk factors to guide treatment decisions in chronic lymphocytic leukemia. Expert Rev Anticancer Ther 2024; 24:977-987. [PMID: 39223949 DOI: 10.1080/14737140.2024.2398483] [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: 05/10/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION In the era of chemo-immunotherapy, high-risk factors unequivocally predicted inferior outcomes for patients with CLL. The widespread adoption of BTK inhibitors has challenged the practical implications of such testing, as many patients have improved outcomes despite the presence of high-risk features. The impact of adverse prognostic factors, such as unmutated IGHV, on survival has been ameliorated by continuous treatment with BTK inhibitors, but not by finite-duration therapy with venetoclax-based combinations. Furthermore, TP53 abnormalities continue to be associated with worse outcomes in the era of novel agents. New treatment modalities, such as pirtobrutinib, lisocabtagene maraleucel, and ongoing studies combining BTK inhibitors with venetoclax, raise new questions on the significance of prognostic factors of survival for patients with CLL. AREAS COVERED Herein, we summarized the available literature on patients with CLL harboring high-risk biomarkers, with a focus on data from key clinical trials. EXPERT OPINION Testing for prognostic biomarkers will remain relevant to identify patients who may have increased benefit from novel therapeutic strategies, such as combination therapies and novel agents. Patients with high-risk disease should be encouraged to participate in clinical trials.
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Affiliation(s)
- Paolo Lopedote
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Adam S Kittai
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexey Danilov
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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2
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Roeker LE, Woyach JA, Cheah CY, Coombs CC, Shah NN, Wierda WG, Patel MR, Lamanna N, Tsai DE, Nair B, Wang C, Zhao X, Liu D, Radtke D, Chapman S, Marella N, McNeely SC, Brown JR. Fixed-duration pirtobrutinib plus venetoclax with or without rituximab in relapsed/refractory CLL: the phase 1b BRUIN trial. Blood 2024; 144:1374-1386. [PMID: 38861666 PMCID: PMC11451378 DOI: 10.1182/blood.2024024510] [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: 03/11/2024] [Revised: 04/30/2024] [Accepted: 05/21/2024] [Indexed: 06/13/2024] Open
Abstract
ABSTRACT Pirtobrutinib is a highly selective, noncovalent (reversible) Bruton tyrosine kinase inhibitor (BTKi). Patients with relapsed or refractory (R/R) chronic lymphocytic leukemia (CLL) were treated with fixed-duration pirtobrutinib plus venetoclax (PV) or pirtobrutinib plus venetoclax and rituximab (PVR) in this phase 1b trial. Prior covalent BTKi therapy was allowed, but not prior treatment with venetoclax. Patients were assigned to receive PV (n = 15) or PVR (n = 10) for 25 cycles. Most patients (68%) had received prior covalent BTKi therapy. At the data cutoff date, the median time on study was 27.0 months for PV and 23.3 months for PVR. Overall response rates were 93.3% (95% confidence interval [CI], 68.1-99.8) for PV and 100% (95% CI, 69.2-100.0) for PVR, with 10 complete responses (PV: 7; PVR: 3). After 12 cycles of treatment, 85.7% (95% CI, 57.2-98.2) of PV and 90.0% (95% CI, 55.5-99.7) of PVR patients achieved undetectable minimal residual disease (<10-4) in peripheral blood. Progression-free survival at 18 months was 92.9% (95% CI, 59.1-99.0) for PV patients and 80.0% (95% CI, 40.9-94.6) for PVR patients. No dose-limiting toxicities were observed during the 5-week assessment period. The most common grade ≥3 adverse events (AEs) for all patients included neutropenia (52%) and anemia (16%). AEs led to dose reduction in 3 patients and discontinuation in 2. In conclusion, fixed-duration PV or PVR was well tolerated and had promising efficacy in patients with R/R CLL, including patients previously treated with a covalent BTKi. This trial was registered at www.clinicaltrials.gov as #NCT03740529.
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MESH Headings
- Humans
- Sulfonamides/administration & dosage
- Sulfonamides/adverse effects
- Sulfonamides/therapeutic use
- Aged
- Middle Aged
- Male
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Female
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/therapeutic use
- Aged, 80 and over
- Adult
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Pyrazoles/administration & dosage
- Pyrazoles/therapeutic use
- Pyrazoles/adverse effects
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Affiliation(s)
| | | | - Chan Y. Cheah
- Linear Clinical Research, Sir Charles Gairdner Hospital, University of Western Australia, Perth, Australia
| | - Catherine C. Coombs
- Division of Hematology and Oncology, Department of Medicine, University of California, Irvine, Orange, CA
| | - Nirav N. Shah
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Manish R. Patel
- Florida Cancer Specialists, Sarah Cannon Research Institute, Sarasota, FL
| | - Nicole Lamanna
- Columbia University Irving Medical Center, NewYork-Presbyterian, New York, NY
| | | | | | | | | | - Dan Liu
- Eli Lilly and Company, Indianapolis, IN
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3
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Huang IJ, Baek GT, Siu C, Shadman M. Pharmacological management of chronic lymphocytic leukemia: current and emerging therapies. Expert Opin Pharmacother 2024:1-25. [PMID: 39211945 DOI: 10.1080/14656566.2024.2398603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL), characterized by its monoclonal lymphoproliferative nature, is an indolent but incurable malignancy. The treatment landscape of CLL/SLL has drastically transformed in the last decade since the introduction of targeted therapy and immune-effector T-cell therapy. The paradigm shift from chemoimmunotherapy to targeted and cellular therapies was largely driven by improved efficacy and safety. With the success of targeted therapies, novel agents and combinations are rapidly emerging on the horizon. AREAS COVERED In this review, we will summarize clinical evidence supporting current and emerging therapies with emphasis on investigational therapies and novel combinations of commercial agents. Clinical trials were identified via clinicaltrials.gov, and a PubMed literature search was last performed in June 2024. EXPERT OPINION With the availability of more effective and better-tolerated treatments for CLL/SLL, the role of early intervention should be further investigated due to its potential to alter disease course, delay progression, and improve overall survival rates. With many highly effective agents and combinations expected to become commercially available, attention to safety profiles and careful selection of patients for each treatment will be critical, with consideration of comorbidities, logistical issues, and financial burden of treatment.
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Affiliation(s)
- Ivan J Huang
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Grace T Baek
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Chloe Siu
- Department of Pharmacy, UW Medicine/Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mazyar Shadman
- Department of Medicine, Division of Hematology and Medical Oncology Division, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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4
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Eichhorst B, Ghia P, Niemann CU, Kater AP, Gregor M, Hallek M, Jerkeman M, Buske C. ESMO Clinical Practice Guideline interim update on new targeted therapies in the first line and at relapse of chronic lymphocytic leukaemia. Ann Oncol 2024; 35:762-768. [PMID: 38969011 DOI: 10.1016/j.annonc.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 06/13/2024] [Accepted: 06/20/2024] [Indexed: 07/07/2024] Open
Affiliation(s)
- B Eichhorst
- Department I for Internal Medicine, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, University of Cologne, Cologne, Germany
| | - P Ghia
- Medical School, Università Vita-Salute San Raffaele, Milan; Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | - C U Niemann
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - A P Kater
- Department of Hematology, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam (LYMMCARE), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M Gregor
- Division of Hematology, Luzerner Kantonsspital, Luzern, Switzerland
| | - M Hallek
- Department I for Internal Medicine, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, University of Cologne, Cologne, Germany; Cluster of Excellence-Cologne Excellence on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
| | - M Jerkeman
- Department of Oncology, Skåne University Hospital and Lund University, Lund, Sweden
| | - C Buske
- Institute of Experimental Cancer Research, Comprehensive Cancer Center Ulm (CCCU), University Hospital of Ulm, Ulm, Germany
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5
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Mauro FR, Frustaci AM, Visentin A, Vitale C, Bartoletti M, Oltolini C, Zappulo E, Mikulska M. Severe infections in patients with chronic lymphocytic leukemia included in trials investigating BTK and BCL2 inhibitors. Crit Rev Oncol Hematol 2024; 201:104408. [PMID: 38880368 DOI: 10.1016/j.critrevonc.2024.104408] [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: 02/28/2024] [Revised: 04/30/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL-2 inhibitor venetoclax have significantly improved the prognosis of patients with chronic lymphocytic leukemia (CLL). However, the incidence of severe infections in patients receiving these agents needs to be better understood. Our review aimed to provide an overview of grade ≥3 infections in patients with CLL who received BTKi and venetoclax-based therapy in prospective trials. Infection rates were influenced by the age of patients and the duration of follow-up. For treatment-naive (TN) patients receiving BTKi, infection rates ranged between 11.4 % and 27.4 % and were close to 30 % in relapsed/refractory (R/R) patients. TN and R/R patients receiving fixed-duration venetoclax-based treatments showed variable rates, with maximum values around 20 %. Opportunistic and fatal infections were uncommon. In conclusion, infections remain a concern in patients with CLL receiving targeted agents. A better definition of factors increasing infection vulnerability could help identify those patients who require infection prophylaxis.
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Affiliation(s)
- Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele Milan 20090, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery University of Naples Federico II, Napoli, Italy
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL) University of Genoa, Italy; Infectious Diseases Unit IRCCS Ospedale Policlinico San Martino Genoa, Italy
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6
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Rios-Olais FA, McGary AK, Tsang M, Almader-Douglas D, Leis JF, Buras MR, Hilal T. Measurable Residual Disease and Clinical Outcomes in Chronic Lymphocytic Leukemia: A Systematic Review and Meta-Analysis. JAMA Oncol 2024; 10:1221-1227. [PMID: 38990562 PMCID: PMC11240229 DOI: 10.1001/jamaoncol.2024.2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 07/12/2024]
Abstract
Importance Measurable residual disease (MRD) refers to the presence of disease at low levels not detected by conventional pathologic analysis. The association of MRD status as a surrogate end point of clinical outcome in chronic lymphocytic leukemia (CLL) has not been established in the era of targeted agents. Assessing the association of MRD with progression-free survival (PFS) may improve its role as a surrogate marker and allow its use to accelerate drug development. Objective To assess the association between MRD and PFS in CLL using data from prospective clinical trials that studied targeted agents or obinutuzumab-based treatment. Data Sources Clinical studies on CLL were identified via searches of PubMed, Embase, Scopus, and Web of Science from inception through July 31, 2023. Study Selection Prospective, single-arm, and randomized clinical trials that assessed targeted agents or obinutuzumab-based treatment and reported PFS by MRD status were included. Studies with insufficient description of MRD information were excluded. Data Extraction and Synthesis Study sample size, median patient age, median follow-up time, line of treatment, MRD detection method and time points, and survival outcomes were extracted. Main Outcomes and Measures Analyses of survival probabilities and hazard ratios (HRs) were conducted for PFS according to MRD status. Meta-analyses were performed using a random-effects model. Results A total of 11 prospective clinical trials (9 randomized and 2 nonrandomized) including 2765 patients were analyzed. Achieving undetectable MRD (uMRD) at 0.01% was associated with an HR of 0.28 (95% CI, 0.20-0.39; P < .001) for PFS. Median PFS was not reached in both groups (uMRD vs MRD), but the estimated 24-month PFS was better in the uMRD group (91.9% [95% CI, 88.8%-95.2%] vs 75.3% [95% CI, 64.7%-87.6%]; P < .001). The association of uMRD with PFS was observed in subgroup analyses in the first-line treatment setting (HR, 0.24; 95% CI, 0.18-0.33), relapsed or refractory disease setting (HR, 0.34; 95% CI, 0.16-0.71), and trials using time-limited therapy (HR, 0.28; 95% CI, 0.19-0.40). Conclusions and Relevance The findings of this systematic review and meta-analysis suggest that assessing MRD status as an end point in clinical trials and as a surrogate of PFS may improve trial efficiency and potentially allow for accelerated drug registration.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Neoplasm, Residual
- Progression-Free Survival
- Treatment Outcome
- Antibodies, Monoclonal, Humanized/therapeutic use
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Affiliation(s)
- Fausto Alfredo Rios-Olais
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alyssa K. McGary
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Phoenix, Arizona
| | - Mazie Tsang
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Jose F. Leis
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
| | - Matthew R. Buras
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Talal Hilal
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
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7
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Boothby A, Hegerova L, Fletcher SN, Shadman M, Johnsen JM. Successful treatment of acquired von Willebrand syndrome secondary to low-grade CLL with rituximab and venetoclax. Leuk Lymphoma 2024:1-3. [PMID: 39155578 DOI: 10.1080/10428194.2024.2392813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/09/2024] [Accepted: 08/10/2024] [Indexed: 08/20/2024]
Affiliation(s)
| | - Livia Hegerova
- Fred Hutch Cancer Center, University of Washington, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Shelley N Fletcher
- Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
| | - Mazyar Shadman
- Fred Hutch Cancer Center, University of Washington, Seattle, WA, USA
| | - Jill M Johnsen
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
- Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA, USA
- Center for Cardiovascular Biology, University of Washington, Seattle, WA, USA
- Washington Center for Bleeding Disorders, Seattle, WA, USA
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8
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Jain N, Wierda WG, O'Brien S. Chronic lymphocytic leukaemia. Lancet 2024; 404:694-706. [PMID: 39068951 DOI: 10.1016/s0140-6736(24)00595-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 02/22/2024] [Accepted: 03/21/2024] [Indexed: 07/30/2024]
Abstract
The last decade has seen remarkable progress in our understanding of disease biology of chronic lymphocytic leukaemia (CLL) and the development of novel targeted therapies. Randomised clinical trials have reported improved progression-free survival and overall survival with targeted therapies compared with chemoimmunotherapy, and thereby the role of chemoimmunotherapy in todays' era for treatment of CLL is limited. Bruton tyrosine kinase (BTK) inhibitors, BCL2 inhibitors, and CD20 monoclonal antibodies have been established as appropriate therapy options for patients with CLL, both as the first-line treatment and in the treatment of relapsed or refractory CLL. Several ongoing phase 3 trials are exploring different combinations of targeted therapies, and the results of these trials might change the treatment framework in first-line treatment of CLL. Non-covalent BTK inhibitors, chimeric antigen receptor T-cell therapy, and other therapeutic strategies are being investigated in relapsed CLL. Some of the therapies used in relapsed CLL, such as non-covalent BTK inhibitors, are now being pursued in earlier lines of therapy, including first-line treatment of CLL.
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Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Division of Hematology/Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA, USA.
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9
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Lewis RI, Vom Stein AF, Hallek M. Targeting the tumor microenvironment for treating double-refractory chronic lymphocytic leukemia. Blood 2024; 144:601-614. [PMID: 38776510 DOI: 10.1182/blood.2023022861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 04/08/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
ABSTRACT The introduction of BTK inhibitors and BCL2 antagonists to the treatment of chronic lymphocytic leukemia (CLL) has revolutionized therapy and improved patient outcomes. These agents have replaced chemoimmunotherapy as standard of care. Despite this progress, a new group of patients is currently emerging, which has become refractory or intolerant to both classes of agents, creating an unmet medical need. Here, we propose that the targeted modulation of the tumor microenvironment provides new therapeutic options for this group of double-refractory patients. Furthermore, we outline a sequential strategy for tumor microenvironment-directed combination therapies in CLL that can be tested in clinical protocols.
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Affiliation(s)
- Richard I Lewis
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Alexander F Vom Stein
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine, Faculty of Medicine, University of Cologne, University Hospital Cologne, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Center for Molecular Medicine Cologne, CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
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10
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Galieni P, Troiani E, Picardi P, Angelini M, Mestichelli F, Dalsass A, Maravalle D, Camaioni E, Bigazzi C, Caraffa P, Ruggieri M, Mazzotta S, Mattioli S, Angelini S. Unmutated IGHV at diagnosis in patients with early stage CLL independently predicts for shorter follow-up time to first treatment (TTFT). Leuk Res 2024; 143:107541. [PMID: 38905908 DOI: 10.1016/j.leukres.2024.107541] [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: 03/13/2024] [Revised: 06/03/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
The mutational status of the IGHV gene is routinely assessed in patients with chronic lymphocytic leukaemia (CLL), since it is both prognostic of clinical outcome and predictive of response to treatment. This study evaluates the IGHV mutational status, assessed in newly diagnosed CLL patients, as a stand-alone predictor of time to first treatment (TTFT). We analysed the data of 236 CLL patients, diagnosed at our centre between January 2004 and September 2020, with a minimum follow-up period of 3.0 years, Binet A-B and Rai 0-II stages. IGHV was unmutated in 38.1 % and mutated in 61.9 % of cases. The univariate analysis showed a statistically significant difference (p < 0.001) in TTFT based on unmutated (85.2 % at 14 years, 95 % CI = 63.3-94.5 %) or mutated (41.3 % at 14 years, 95 % CI = 29.5-51.8 %) and the need for treatment at 1, 3 and 5 years was of 20.0 % vs 4.1 % (p < 0.001), 42.7 % vs 11.4 % (p < 0.001) and 55.8 % vs 20.0 % (p < 0.001) in unmutated and mutated IGHV patients, respectively. Multivariate analysis confirmed that unmutated IGHV status negatively affects TTFT (p < 0.001), in addition to high-risk genomic aberration (p = 0.025), Rai stage I (p = 0.007) and II (p-value < 0.001). The difference in TTFT based on unmutated or mutated IGHV status remains statistically significant also when considering the subgroups by the genomic aberrations and Rai stages. Our findings suggest that, with the single analysis of the IGHV mutational status at CLL diagnosis, along with clinical and laboratory data, and without karyotype and TP53 data, clinicians will have prognostic and predictive indications for the first clinical treatment and appropriate follow-up of patients.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Female
- Middle Aged
- Aged
- Mutation
- Follow-Up Studies
- Prognosis
- Adult
- Aged, 80 and over
- Immunoglobulin Heavy Chains/genetics
- Time-to-Treatment
- Immunoglobulin Variable Region/genetics
- Neoplasm Staging
- Retrospective Studies
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Affiliation(s)
- Piero Galieni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy.
| | - Emanuela Troiani
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paola Picardi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Mario Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Francesca Mestichelli
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Alessia Dalsass
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Denise Maravalle
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Elisa Camaioni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Catia Bigazzi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Patrizia Caraffa
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Miriana Ruggieri
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Serena Mazzotta
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Silvia Mattioli
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Stefano Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
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11
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Kater AP, Eichhorst BF, Owen CJ, Jaeger U, Chyla B, Lefebure M, Millen R, Jiang Y, Thadani‐Mulero M, Boyer M, Seymour JF. Long-term immune changes in patients with relapsed/refractory chronic lymphocytic leukemia following treatment with venetoclax plus rituximab. Hemasphere 2024; 8:e146. [PMID: 39193190 PMCID: PMC11347997 DOI: 10.1002/hem3.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/22/2024] [Accepted: 06/04/2024] [Indexed: 08/29/2024] Open
Abstract
Immune dysregulation is a hallmark of chronic lymphocytic leukemia (CLL). Anti-CD20 antibodies (e.g., rituximab [R]) can be combined with venetoclax (Ven) to treat CLL. However, anti-CD20 antibodies can increase hypogammaglobulinemia risk, while the effects of Ven on immune dysregulation are still uncertain. We report long-term immune changes in VenR- and bendamustine-R (BR)-treated patients with relapsed/refractory CLL in the MURANO trial (NCT02005471). Patients were randomized to fixed-duration VenR (2 years Ven; VenR for the first 6 months) or BR (6 months). Immune cell levels were evaluated at the end of combination treatment (EOCT), end of treatment (EOT; VenR arm only), and 12 and 24 months post-EOCT. Overall, 130/194 VenR- and 134/195 BR-treated patients completed treatment without progressive disease. In patients who completed VenR combination therapy, median immunoglobulin (Ig)G and IgM levels decreased from baseline to EOT (p ≤ 0.01 and p ≤ 0.0001, respectively); by 24 months, post-EOT IgG had returned to baseline level and IgM had increased from baseline (p ≤ 0.001). Median IgA levels increased from baseline to 12 (p ≤ 0.0001) and 24 months post-EOT (p ≤ 0.0001). In BR-treated patients, changes in IgG, IgA, and IgM levels across the assessed time points were not significant, and by 24 months, post-EOCT IgG, IgA, and IgM were above baseline levels. Grade ≥3 infection rates on treatment were low. Overall, immune recovery was observed with VenR and BR, with stabilization of Ig levels after treatment. Post-treatment infection rates were generally low, making these very tolerable therapies for CLL.
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Affiliation(s)
- Arnon P. Kater
- Department of Hematology, Cancer Center Amsterdam, LYMMCARE, Amsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Barbara F. Eichhorst
- Department of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Dusseldorf (CIO ABCD), Faculty of Medicine and University Hospital CologneUniversity of CologneCologneGermany
| | - Carolyn J. Owen
- Departments of Medicine and OncologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Ulrich Jaeger
- Clinical Department of Hematology and HemostaseologyMedical University of ViennaViennaAustria
| | | | | | | | | | | | | | - John F. Seymour
- Peter MacCallum Cancer CentreRoyal Melbourne Hospital and University of MelbourneMelbourneAustralia
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12
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Monica M, Reczek M, Kawalec P. Network meta-analysis of novel targeted therapies for relapsed/refractory chronic lymphocytic leukemia. Ther Adv Med Oncol 2024; 16:17588359241263710. [PMID: 39091602 PMCID: PMC11292688 DOI: 10.1177/17588359241263710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 06/06/2024] [Indexed: 08/04/2024] Open
Abstract
Background The recent development of new antileukemic therapies (anti-CD20 monoclonal antibodies, Bruton tyrosine kinase inhbitors, phosphoinositide 3-kinase inhibitors, and B-cell lymyphoma-2 antagonists) improved the progression-free survival (PFS) compared with selected standard regimens in clinical trials for patients with relapsed/refractory chronic lymphocytic leukemia (CLL). Unfortunately, the relative efficacy of all possible therapeutic options remains unknown because there is no direct evidence for all possible comparisons. Objectives We aimed to compare the efficacy and safety of novel agents, chemotherapy, and immunotherapy using a Bayesian network meta-analysis (NMA). Design Systematic literature review with Bayesian NMA. Methods An extensive systematic literature review of randomized clinical trials for relapsed/refractory CLL was performed. We searched for articles indexed in medical databases (MEDLINE, Embase, The Cochrane Library) and gray literature that could be further implemented into the Bayesian NMA. Results The systematic search identified 15 randomized trials that formed networks comparing PFS, overall survival (OS), overall response rates, and serious adverse events. Our study showed that all regimens containing novel agents significantly prolonged PFS compared with standard chemoimmunotherapy and immunotherapy. Among targeted drugs, venetoclax (VEN) + rituximab (RTX) had comparable efficacy in terms of PFS to zanubrutinib (ZAN) [hazard ratio (95% credible interval), 1.10 (0.59-2.08)], acalabrutinib (ACA) [0.78 (0.47-1.30)], ibrutinib (IBR) monotherapy [0.72 (0.41-1.27)], and other IBR-based regimens. ZAN was superior to IBR monotherapy [0.65 (0.49-0.86)] but not to ACA [0.71 (0.49-1.02)]. There were no significant differences in OS in any of the above comparisons. Conclusion All novel therapies have better efficacy than chemoimmunotherapy and immunotherapy regimens. Among novel agents, the relative efficacy of VEN + RTX was similar to all BTKi, while ZAN was superior to IBR and comparable to ACA. Trial registration PROSPERO CRD42022304330.
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Affiliation(s)
- Magdalena Monica
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Łazarza 16, Kraków 31-530, Poland
- Department of Nutrition and Drug Research, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | | | - Paweł Kawalec
- Department of Nutrition and Drug Research, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
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13
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Urso A, Martino EA, Cuneo A, Gentile M, Rigolin GM. Chronic Lymphocytic Leukemia: Prognostic Factors in the Era of Novel Drugs. Cancers (Basel) 2024; 16:2732. [PMID: 39123460 PMCID: PMC11311700 DOI: 10.3390/cancers16152732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
Novel drugs have profoundly changed the outcomes in chronic lymphocytic leukemia (CLL) patients, and the traditional prognostic factors that were identified in the era of chemoimmunotherapy need to be validated in the context of these new targeted therapies. Currently, the most important prognostic genetic biomarkers are the immunoglobulin heavy chain variable (IGHV) mutational status, genetic aberrations including del(17p)/TP53 abnormalities, and the complex karyotype. In this review, we discuss the prognostic role of these genomic markers in relation to novel treatments. Moreover, we present and discuss new scoring systems that were elaborated and validated in the era of new drugs. In routine clinical practice, the application of an extensive genomic work-up with validated prognostic markers could improve the identification of "very high-risk" CLL patients who could benefit from novel, more effective targeted treatments.
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Affiliation(s)
- Antonio Urso
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
| | | | - Antonio Cuneo
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera Annunziata, 87100 Cosenza, Italy; (E.A.M.); (M.G.)
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, 87036 Rende, Italy
| | - Gian Matteo Rigolin
- Hematology Unit, St Anna University Hospital, 44124 Ferrara, Italy; (A.U.); (A.C.)
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14
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Opat S. Treatment of relapsed CLL "in the BAAG"? Blood 2024; 144:243-244. [PMID: 39023867 DOI: 10.1182/blood.2024024790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
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15
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Davids MS, Sharman JP, Ghia P, Woyach JA, Eyre TA, Jurczak W, Siddiqi T, Miranda P, Shahkarami M, Butturini A, Emeribe U, Byrd JC. Acalabrutinib-based regimens in frontline or relapsed/refractory higher-risk CLL: pooled analysis of 5 clinical trials. Blood Adv 2024; 8:3345-3359. [PMID: 38640349 PMCID: PMC11255369 DOI: 10.1182/bloodadvances.2023011307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 03/29/2024] [Accepted: 04/07/2024] [Indexed: 04/21/2024] Open
Abstract
ABSTRACT Before targeted therapies, patients with higher-risk chronic lymphocytic leukemia (CLL), defined as del(17p) and/or TP53 mutation (TP53m), unmutated immunoglobulin heavy chain variable region genes (uIGHV), or complex karyotype (CK), had poorer prognosis with chemoimmunotherapy. Bruton tyrosine kinase inhibitors (BTKis) have demonstrated benefit in higher-risk patient populations with CLL in individual trials. To better understand the impact of the second-generation BTKi acalabrutinib, we pooled data from 5 prospective clinical studies of acalabrutinib as monotherapy or in combination with obinutuzumab (ACE-CL-001, ACE-CL-003, ELEVATE-TN, ELEVATE-RR, and ASCEND) in patients with higher-risk CLL in treatment-naive (TN) or relapsed/refractory (R/R) cohorts. A total of 808 patients were included (TN cohort, n = 320; R/R cohort, n = 488). Median follow-up was 59.1 months (TN cohort) and 44.3 months (R/R cohort); 51.3% and 26.8% of patients in the TN and R/R cohorts, respectively, remained on treatment at last follow-up. In the del(17p)/TP53m, uIGHV, and CK subgroups in the TN cohort, median progression-free survival (PFS) and median overall survival (OS) were not reached (NR). In the del(17p)/TP53m, uIGHV, and CK subgroups in the R/R cohort, median PFS was 38.6 months, 46.9 months, and 38.6 months, respectively, and median OS was 60.6 months, NR, and NR, respectively. The safety profile of acalabrutinib-based therapy in this population was consistent with the known safety profile of acalabrutinib in a broad CLL population. Our analysis demonstrates long-term benefit of acalabrutinib-based regimens in patients with higher-risk CLL, regardless of line of therapy.
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MESH Headings
- Humans
- Pyrazines/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Benzamides/therapeutic use
- Male
- Aged
- Female
- Middle Aged
- Aged, 80 and over
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Recurrence
- Clinical Trials as Topic
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Treatment Outcome
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Affiliation(s)
- Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jeff P. Sharman
- Willamette Valley Cancer Institute and Research Center/US Oncology Research, Eugene, OR
| | - Paolo Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele, Milan, Italy
- Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Toby A. Eyre
- Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Wojciech Jurczak
- Maria Skłodowska-Curie National Research Institute of Oncology, Krakow, Poland
| | - Tanya Siddiqi
- City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | | | | | | | - John C. Byrd
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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16
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Malcikova J, Pavlova S, Baliakas P, Chatzikonstantinou T, Tausch E, Catherwood M, Rossi D, Soussi T, Tichy B, Kater AP, Niemann CU, Davi F, Gaidano G, Stilgenbauer S, Rosenquist R, Stamatopoulos K, Ghia P, Pospisilova S. ERIC recommendations for TP53 mutation analysis in chronic lymphocytic leukemia-2024 update. Leukemia 2024; 38:1455-1468. [PMID: 38755420 PMCID: PMC11217004 DOI: 10.1038/s41375-024-02267-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/18/2024]
Abstract
In chronic lymphocytic leukemia (CLL), analysis of TP53 aberrations (deletion and/or mutation) is a crucial part of treatment decision-making algorithms. Technological and treatment advances have resulted in the need for an update of the last recommendations for TP53 analysis in CLL, published by ERIC, the European Research Initiative on CLL, in 2018. Based on the current knowledge of the relevance of low-burden TP53-mutated clones, a specific variant allele frequency (VAF) cut-off for reporting TP53 mutations is no longer recommended, but instead, the need for thorough method validation by the reporting laboratory is emphasized. The result of TP53 analyses should always be interpreted within the context of available laboratory and clinical information, treatment indication, and therapeutic options. Methodological aspects of introducing next-generation sequencing (NGS) in routine practice are discussed with a focus on reliable detection of low-burden clones. Furthermore, potential interpretation challenges are presented, and a simplified algorithm for the classification of TP53 variants in CLL is provided, representing a consensus based on previously published guidelines. Finally, the reporting requirements are highlighted, including a template for clinical reports of TP53 aberrations. These recommendations are intended to assist diagnosticians in the correct assessment of TP53 mutation status, but also physicians in the appropriate understanding of the lab reports, thus decreasing the risk of misinterpretation and incorrect management of patients in routine practice whilst also leading to improved stratification of patients with CLL in clinical trials.
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Affiliation(s)
- Jitka Malcikova
- Department of Internal Medicine, Hematology and Oncology, and Institute of Medical Genetics and Genomics, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Sarka Pavlova
- Department of Internal Medicine, Hematology and Oncology, and Institute of Medical Genetics and Genomics, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Panagiotis Baliakas
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Mark Catherwood
- Haematology Department, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Davide Rossi
- Hematology, Oncology Institute of Southern Switzerland and Institute of Oncology Research, Università della Svizzera Italiana, Bellinzona, Switzerland
| | - Thierry Soussi
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Hematopoietic and Leukemic Development, UMRS_938, Sorbonne University, Paris, France
| | - Boris Tichy
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Frederic Davi
- Sorbonne Université, Paris, France
- Department of Hematology, Hôpital Pitié-Salpêtière, AP-HP, Paris, France
| | - Gianluca Gaidano
- Division of Haematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Richard Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Clinical Genetics and Genomics, Karolinska University Hospital, Stockholm, Sweden
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Paolo Ghia
- Università Vita-Salute San Raffaele, Milan, Italy.
- Strategic Research Program on CLL, Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Milan, Italy.
| | - Sarka Pospisilova
- Department of Internal Medicine, Hematology and Oncology, and Institute of Medical Genetics and Genomics, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic.
- Central European Institute of Technology, Masaryk University, Brno, Czech Republic.
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17
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Kutsch N, Robrecht S, Fink A, Lange E, Weide R, Kiehl MG, Sökler M, Schlag R, Vehling‐Kaiser U, Köchling G, Plöger C, Gregor M, Plesner T, Clausen MR, Oschlies I, Ritgen M, Herling M, Fischer K, Döhner H, Wendtner C, Kreuzer K, Stilgenbauer S, Hallek M, Böttcher S, Klapper W, Eichhorst B. The role of trephine bone marrow biopsies in the era of measurable residual disease -Results from the CLL10 trial of the German CLL Study Group (GCLLSG). Hemasphere 2024; 8:e126. [PMID: 39050548 PMCID: PMC11267170 DOI: 10.1002/hem3.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/10/2024] [Accepted: 06/25/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Sandra Robrecht
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Anna Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Elisabeth Lange
- Department of Hematology and OncologyEvangelical Hospital HammHammGermany
| | - Rudolf Weide
- Practice for Hematology and OncologyKoblenzGermany
| | - Michael G. Kiehl
- Department of Internal MedicineFrankfurt (Oder) General HospitalFrankfurt/OderGermany
| | - Martin Sökler
- Department II of Internal MedicineUniversity Hospital TübingenTübingenGermany
- Department of Hematology and OncologyHospital STS AG ThunThunSwitzerland
| | | | | | | | | | - Michael Gregor
- Division of HematologyCantonal Hospital of LucerneLucerneSwitzerland
| | - Torben Plesner
- Department of Hematology and University of Southern DenmarkVejle HospitalVejleDenmark
| | - Michael R. Clausen
- Department of Hematology and University of Southern DenmarkVejle HospitalVejleDenmark
| | - Ilske Oschlies
- Hematopathology SectionChristian‐Albrechts‐University KielKielGermany
| | - Matthias Ritgen
- Department II of Internal MedicineUniversity of Schleswig‐HolsteinKielGermany
| | - Marco Herling
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
- Department of Hematology, Cellular Therapy, Hemostaseology and InfectiologyUniversity Hospital LeipzigLeipzigGermany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Hartmut Döhner
- Department III of Internal MedicineUniversity Hospital of UlmUlmGermany
| | | | - Karl‐Anton Kreuzer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Stephan Stilgenbauer
- Department of Hematology and OncologyHospital STS AG ThunThunSwitzerland
- Department of Hematology, Cellular Therapy, Hemostaseology and InfectiologyUniversity Hospital LeipzigLeipzigGermany
| | - Michael Hallek
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
| | - Sebastian Böttcher
- Department III of Internal Medicine Medicine—Hematology/Oncology/Palliative CareRostock University Medical CenterRostockGermany
| | - Wolfram Klapper
- Hematopathology SectionChristian‐Albrechts‐University KielKielGermany
| | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf and German CLL Study GroupUniversity of CologneCologneGermany
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18
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Aruga Y, Ikeda C, Matsushita H, Makita S, Fukuhara S, Munakata W, Izutsu K, Matsui H. The kappa/lambda ratio of surface immunoglobulin light chain as a valuable parameter for MRD assessment in CLL with atypical immunophenotype. Sci Rep 2024; 14:13452. [PMID: 38862612 PMCID: PMC11166639 DOI: 10.1038/s41598-024-64398-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 06/07/2024] [Indexed: 06/13/2024] Open
Abstract
In recent years, the significance of detecting minimal/measurable residual disease (MRD) in chronic lymphocytic leukemia (CLL) has increased due to the availability of highly effective therapeutic agents. Flow cytometry provides notable cost-effectiveness and immediacy, with an expected sensitivity level of approximately 10-4. The critical aspect of MRD detection via flow cytometry lies in accurately defining the region containing tumor cells. However, a subset of CLL, known as CLL with atypical immunophenotype, exhibits a distinct cell surface marker expression pattern that can make MRD detection challenging, because these markers often resemble those of normal B cells. To enhance the sensitivity of MRD detection in such atypical cases of CLL, we have capitalized on the observation that cell surface immunoglobulin (sIg) light chains tend to be expressed at a higher level in this subtype. For every four two-dimensional plots of cell surface markers, we used a plot to evaluate the expression of sIg kappa/lambda light chains and identified regions where the kappa/lambda ratio of sIg light chains deviated from a designated threshold within the putative CLL cell region. Using this method, we could detect atypical CLL cells at a level of 10-4. We propose this method as an effective MRD assay.
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Affiliation(s)
- Yu Aruga
- Department of Laboratory Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Medical Oncology and Translational Research, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Chiaki Ikeda
- Department of Laboratory Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Hiromichi Matsushita
- Department of Laboratory Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinichi Makita
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Suguru Fukuhara
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Wataru Munakata
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Izutsu
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
| | - Hirotaka Matsui
- Department of Laboratory Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
- Department of Medical Oncology and Translational Research, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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19
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Al-Sawaf O, Jen MH, Hess LM, Zhang J, Goebel B, Pagel JM, Abhyankar S, Davids MS, Eyre TA. Pirtobrutinib versus venetoclax in covalent Bruton tyrosine kinase inhibitor-pretreated chronic lymphocytic leukemia: a matching-adjusted indirect comparison. Haematologica 2024; 109:1866-1873. [PMID: 38031799 PMCID: PMC11141664 DOI: 10.3324/haematol.2023.284150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023] Open
Abstract
Venetoclax is a standard treatment for patients with chronic lymphocytic leukemia (CLL) following covalent Bruton tyrosine kinase inhibitor (cBTKi) therapy, despite relatively limited prospective data in this setting. Pirtobrutinib is a highly selective, non-covalent (reversible) BTKi that was designed to overcome the pharmacologic limitations of cBTKi and re-establish BTK inhibition. An unanchored matching-adjusted indirect comparison (MAIC) was conducted to estimate the treatment effect of pirtobrutinib versus venetoclax monotherapy in patients with cBTKi-pretreated CLL. Data from patients with CLL who were venetoclax-naïve and pretreated with cBTKi received pirtobrutinib (N=146) in the phase I/II BRUIN study were compared with the only identified trial of patients with CLL receiving venetoclax after a cBTKi (N=91), as administered as monotherapy until progression. Outcomes included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), and treatment-emergent adverse events. Both unweighted and weighted analyses were conducted. PFS and OS of pirtobrutinib and venetoclax were comparable in both unweighted and weighted analyses (weighted hazard ratios for PFS: 1.01, 95% confidence interval [CI]: 0.58-1.73, P=0.98 and OS: 0.64, 95% CI: 0.25-1.67, P=0.34). ORR was significantly higher for pirtobrutinib (80.2% vs. 64.8%, P=0.01). Grade ≥3 treatment-emergent adverse events were lower in weighted analyses for pirtobrutinib versus venetoclax (all P<0.01), except for pneumonia, which was similar. These results suggest that pirtobrutinib may also be considered as an effective and well-tolerated treatment for patients with relapsed CLL following cBTKi.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany; Cancer Institute, University College London, United Kingdom; Francis Crick Institute, London.
| | | | | | | | | | | | | | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Toby A Eyre
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford
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20
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Fürstenau M, Kater AP, Robrecht S, von Tresckow J, Zhang C, Gregor M, Thornton P, Staber PB, Tadmor T, Lindström V, Juliusson G, Janssens A, Levin MD, da Cunha-Bang C, Schneider C, Goldschmidt N, Vandenberghe E, Rossi D, Benz R, Nösslinger T, Heintel D, Poulsen CB, Christiansen I, Frederiksen H, Enggaard L, Posthuma EFM, Issa DE, Visser HPJ, Bellido M, Kutsch N, Dürig J, Stehle A, Vöhringer M, Böttcher S, Schulte C, Simon F, Fink AM, Fischer K, Holmes EE, Kreuzer KA, Ritgen M, Brüggemann M, Tausch E, Stilgenbauer S, Hallek M, Niemann CU, Eichhorst B. First-line venetoclax combinations versus chemoimmunotherapy in fit patients with chronic lymphocytic leukaemia (GAIA/CLL13): 4-year follow-up from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 2024; 25:744-759. [PMID: 38821083 DOI: 10.1016/s1470-2045(24)00196-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND In the primary analysis report of the GAIA/CLL13 trial, we found that venetoclax-obinutuzumab and venetoclax-obinutuzumab-ibrutinib improved undetectable measurable residual disease (MRD) rates and progression-free survival compared with chemoimmunotherapy in patients with previously untreated chronic lymphocytic leukaemia. However, to our knowledge, no data on direct comparisons of different venetoclax-based combinations are available. METHODS GAIA/CLL13 is an open-label, randomised, phase 3 study conducted at 159 sites in ten countries in Europe and the Middle East. Eligible patients were aged 18 years or older, with a life expectancy of at least 6 months, an Eastern Cooperative Oncology group performance status of 0-2, a cumulative illness rating scale score of 6 or lower or a single score of 4 or lower, and no TP53 aberrations. Patients were randomly assigned (1:1:1:1), with a computer-generated list stratified by age, Binet stage, and regional study group, to either chemoimmunotherapy, venetoclax-rituximab, venetoclax-obinutuzumab, or venetoclax-obinutuzumab-ibrutinib. All treatments were administered in 28-day cycles. Patients in the chemoimmunotherapy group received six cycles of treatment, with patients older than 65 years receiving intravenous bendamustine (90 mg/m2, days 1-2), whereas patients aged 65 years or younger received intravenous fludarabine (25 mg/m2, days 1-3) and intravenous cyclophosphamide (250 mg/m2, days 1-3). Intravenous rituximab (375 mg/m2, day 1 of cycle 1; 500 mg/m2, day 1 of cycles 2-6) was added to chemotherapy. In the experimental groups, patients received daily venetoclax (400 mg orally) for ten cycles after a 5-week ramp-up phase starting on day 22 of cycle 1. In the venetoclax-rituximab group, intravenous rituximab (375 mg/m2, day 1 of cycle 1; 500 mg/m2, day 1 of cycles 2-6) was added. In the obinutuzumab-containing groups, obinutuzumab was added (cycle 1: 100 mg on day 1, 900 mg on day 2, and 1000 mg on days 8 and 15; cycles 2-6: 1000 mg on day 1). In the venetoclax-obinutuzumab-ibrutinib group, daily ibrutinib (420 mg orally, from day 1 of cycle 1) was added until undetectable MRD was reached in two consecutive measurements (3 months apart) or until cycle 36. The planned treatment duration was six cycles in the chemoimmunotherapy group, 12 cycles in the venetoclax-rituximab and the venetoclax-obinutuzumab group and between 12 and 36 cycles in the venetoclax-obinutuzumab-ibrutinib group. Coprimary endpoints were the undetectable MRD rate in peripheral blood at month 15 for the comparison of venetoclax-obinutuzumab versus standard chemoimmunotherapy and investigator-assessed progression-free survival for the comparison of venetoclax-obinutuzumab-ibrutinib versus standard chemoimmunotherapy, both analysed in the intention-to-treat population (ie, all patients randomly assigned to treatment) with a split α of 0·025 for each coprimary endpoint. Both coprimary endpoints have been reported elsewhere. Here we report a post-hoc exploratory analysis of updated progression-free survival results after a 4-year follow-up of our study population. Safety analyses included all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT02950051, recruitment is complete, and all patients are off study treatment. FINDINGS Between Dec 13, 2016, and Oct 13, 2019, 1080 patients were screened and 926 were randomly assigned to treatment (chemoimmunotherapy group n=229; venetoclax-rituximab group n=237; venetoclax-obinutuzumab group n=229; and venetoclax-obinutuzumab-ibrutinib group n=231); mean age 60·8 years (SD 10·2), 259 (28%) of 926 patients were female, and 667 (72%) were male (data on race and ethnicity are not reported). At data cutoff for this exploratory follow-up analysis (Jan 31, 2023; median follow-up 50·7 months [IQR 44·6-57·9]), patients in the venetoclax-obinutuzumab group had significantly longer progression-free survival than those in the chemoimmunotherapy group (hazard ratio [HR] 0·47 [97·5% CI 0·32-0·69], p<0·0001) and the venetoclax-rituximab group (0·57 [0·38-0·84], p=0·0011). The venetoclax-obinutuzumab-ibrutinib group also had a significantly longer progression-free survival than the chemoimmunotherapy group (0·30 [0·19-0·47]; p<0·0001) and the venetoclax-rituximab group (0·38 [0·24-0·59]; p<0·0001). There was no difference in progression-free survival between the venetoclax-obinutuzumab-ibrutinib and venetoclax-obinutuzumab groups (0·63 [0·39-1·02]; p=0·031), and the proportional hazards assumption was not met for the comparison between the venetoclax-rituximab group versus the chemoimmunotherapy group (log-rank p=0·10). The estimated 4-year progression-free survival rate was 85·5% (97·5% CI 79·9-91·1; 37 [16%] events) in the venetoclax-obinutuzumab-ibrutinib group, 81·8% (75·8-87·8; 55 [24%] events) in the venetoclax-obinutuzumab group, 70·1% (63·0-77·3; 84 [35%] events) in the venetoclax-rituximab group, and 62·0% (54·4-69·7; 90 [39%] events) in the chemoimmunotherapy group. The most common grade 3 or worse treatment-related adverse event was neutropenia (114 [53%] of 216 patients in the chemoimmunotherapy group, 109 [46%] of 237 in the venetoclax-rituximab group, 127 [56%] of 228 in the venetoclax-obinutuzumab group, and 112 [48%] of 231 in the venetoclax-obinutuzumab-ibrutinib group). Deaths determined to be associated with study treatment by the investigator occurred in three (1%) patients in the chemoimmunotherapy group (n=1 due to each of sepsis, metastatic squamous cell carcinoma, and Richter's syndrome), none in the venetoclax-rituximab and venetoclax-obinutuzumab groups, and four (2%) in the venetoclax-obinutuzumab-ibrutinib group (n=1 due to each of acute myeloid leukaemia, fungal encephalitis, small-cell lung cancer, and toxic leukoencephalopathy). INTERPRETATION With more than 4 years of follow-up, venetoclax-obinutuzumab and venetoclax-obinutuzumab-ibrutinib significantly extended progression-free survival compared with both chemoimmunotherapy and venetoclax-rituximab in previously untreated, fit patients with chronic lymphocytic leukaemia, thereby supporting their use and further evaluation in this patient group, while still considering the higher toxicities observed with the triple combination. FUNDING AbbVie, Janssen, and F Hoffmann-La Roche.
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MESH Headings
- Humans
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Sulfonamides/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Female
- Aged
- Middle Aged
- Follow-Up Studies
- Piperidines/administration & dosage
- Vidarabine/analogs & derivatives
- Vidarabine/administration & dosage
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Adenine/analogs & derivatives
- Adenine/administration & dosage
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Progression-Free Survival
- Cyclophosphamide/administration & dosage
- Pyrazoles/administration & dosage
- Pyrimidines/administration & dosage
- Immunotherapy
- Adult
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Affiliation(s)
- Moritz Fürstenau
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany.
| | - Arnon P Kater
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Sandra Robrecht
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Can Zhang
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Michael Gregor
- Division of Hematology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | | | - Philipp B Staber
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Tamar Tadmor
- Hematology, Bnai-Zion Medical Center, Haifa, Israel
| | - Vesa Lindström
- Comprehensive Cancer Center, Department of Hematology, Helsinki University Hospital and University of Helsinki, Finland
| | - Gunnar Juliusson
- Department of Hematology, Skåne University Hospital, Lund, Sweden
| | - Ann Janssens
- Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Caspar da Cunha-Bang
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christof Schneider
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
| | | | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland and Institute of Oncology Research, EOC and USI, Bellinzona, Switzerland
| | - Rudolf Benz
- Division of Hematology and Oncology, Cantonal Hospital, Münsterlingen, Switzerland
| | - Thomas Nösslinger
- Medical University of Vienna, and the Department of Hematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Daniel Heintel
- Division of Medicine I, Klinik Ottakring, Vienna, Austria
| | | | - Ilse Christiansen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | | | - Hein P J Visser
- Department of Internal Medicine, Noordwest ziekenhuisgroep, Alkmaar, Netherlands
| | - Mar Bellido
- Department of Hematology, Groningen University Medical Center, University of Groningen, Groningen, Netherlands
| | - Nadine Kutsch
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Jan Dürig
- Department of Internal Medicine, St Josef Krankenhaus Werden, University Medicine Essen, Essen, Germany
| | - Alexander Stehle
- Department of Hematology and Oncology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Matthias Vöhringer
- Department of Hematology and Oncology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Sebastian Böttcher
- Department of Medicine III Hematology, Oncology and Palliative Care, University Hospital Rostock, Rostock, Germany
| | - Clemens Schulte
- Gemeinschaftspraxis für Hämatologie und Onkologie, Dortmund, Germany
| | - Florian Simon
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Emily E Holmes
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Monika Brüggemann
- Department II of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Michael Hallek
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Carsten U Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Barbara Eichhorst
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
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21
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Del Giudice I, Della Starza I, De Falco F, Gaidano G, Sportoletti P. Monitoring Response and Resistance to Treatment in Chronic Lymphocytic Leukemia. Cancers (Basel) 2024; 16:2049. [PMID: 38893168 PMCID: PMC11171231 DOI: 10.3390/cancers16112049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/09/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
The recent evolution in chronic lymphocytic leukemia (CLL) targeted therapies led to a progressive change in the way clinicians manage the goals of treatment and evaluate the response to treatment in respect to the paradigm of the chemoimmunotherapy era. Continuous therapies with BTK inhibitors achieve prolonged and sustained control of the disease. On the other hand, venetoclax and anti-CD20 monoclonal antibodies or, more recently, ibrutinib plus venetoclax combinations, given for a fixed duration, achieve undetectable measurable residual disease (uMRD) in the vast majority of patients. On these grounds, a time-limited MRD-driven strategy, a previously unexplored scenario in CLL, is being attempted. On the other side of the spectrum, novel genetic and non-genetic mechanisms of resistance to targeted treatments are emerging. Here we review the response assessment criteria, the evolution and clinical application of MRD analysis and the mechanisms of resistance according to the novel treatment strategies within clinical trials. The extent to which this novel evidence will translate in the real-life management of CLL patients remains an open issue to be addressed.
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Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
| | - Irene Della Starza
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
- AIL Roma, ODV, 00161 Rome, Italy
| | - Filomena De Falco
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
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22
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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A. Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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23
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Mouhssine S, Maher N, Kogila S, Cerchione C, Martinelli G, Gaidano G. Current Therapeutic Sequencing in Chronic Lymphocytic Leukemia. Hematol Rep 2024; 16:270-282. [PMID: 38804280 PMCID: PMC11130833 DOI: 10.3390/hematolrep16020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/20/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024] Open
Abstract
The treatment landscape of chronic lymphocytic leukemia (CLL), the most frequent leukemia in adults, is constantly changing. CLL patients can be divided into three risk categories, based on their IGHV mutational status and the occurrence of TP53 disruption and/or complex karyotype. For the first-line treatment of low- and intermediate-risk CLL, both the BCL2 inhibitor venetoclax plus obinutuzumab and the second generation BTK inhibitors (BTKi), namely acalabrutinib and zanubrutinib, are valuable and effective options. Conversely, venetoclax-based fixed duration therapies have not shown remarkable results in high-risk CLL patients, while continuous treatment with acalabrutinib and zanubrutinib displayed favorable outcomes, similar to those obtained in TP53 wild-type patients. The development of acquired resistance to pathway inhibitors is still a clinical challenge, and the optimal treatment sequencing of relapsed/refractory CLL is not completely established. Covalent BTKi-refractory patients should be treated with venetoclax plus rituximab, whereas venetoclax-refractory CLL may be treated with second generation BTKi in the case of early relapse, while venetoclax plus rituximab might be used if late relapse has occurred. On these grounds, here we provide an overview of the current state-of-the-art therapeutic algorithms for treatment-naïve patients, as well as for relapsed/refractory disease.
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Affiliation(s)
- Samir Mouhssine
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Nawar Maher
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Sreekar Kogila
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
| | - Claudio Cerchione
- Hematology Unit, Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori”—IRST IRCCS, 47014 Meldola, Italy;
| | - Giovanni Martinelli
- Department of Hematology and Sciences Oncology, Institute of Haematology “L. and A. Seràgnoli”, S. Orsola University Hospital, 40138 Bologna, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy; (S.M.); (N.M.); (S.K.)
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24
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Stilgenbauer S, Tausch E, Roberts AW, Davids MS, Eichhorst B, Hallek M, Hillmen P, Schneider C, Schetelig J, Böttcher S, Kater AP, Jiang Y, Boyer M, Popovic R, Ghanim MT, Moran M, Sinai WJ, Wang X, Mukherjee N, Chyla B, Wierda WG, Seymour JF. Six-year follow-up and subgroup analyses of a phase 2 trial of venetoclax for del(17p) chronic lymphocytic leukemia. Blood Adv 2024; 8:1992-2004. [PMID: 38290108 PMCID: PMC11024923 DOI: 10.1182/bloodadvances.2023011741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 02/01/2024] Open
Abstract
ABSTRACT Chromosome 17p deletion (del[17p]) is associated with poor prognosis in patients with chronic lymphocytic leukemia (CLL). Venetoclax is approved for treatment of previously untreated and relapsed/refractory (R/R) CLL, including patients with del(17p), based on the open-label, multicenter, phase 2 M13-982 trial (NCT01889186). Here, we detail the 6-year follow-up analysis for M13-982. A total of 158 patients with previously untreated (n = 5) or R/R (n = 153) del(17p) CLL received 400 mg venetoclax daily after initial ramp-up until progressive disease. After a median follow-up of 70 months, the best objective response rate (ORR) was 77% (21% complete remission [CR] and 49% partial remission [PR]), with a median duration of response (DOR) of 39.3 months (95% confidence interval [CI], 31.1-50.5). The median progression-free survival (PFS) was 28.2 months (95% CI, 23.4-37.6), and median overall survival (OS) was 62.5 months (95% CI, 51.7-not reached), with 16% of patients remaining on treatment after 6 years. Multivariable analysis did not identify statistically significant correlation between patient subgroups defined by clinical or laboratory variables and ORR or PFS. The most common grade ≥3 adverse events were neutropenia (42%), infections (33%), anemia (16%), and thrombocytopenia (16%). Post hoc comparative analyses of PFS and OS from treatment initiation, from a 24-month landmark, and by minimal residual disease status were performed between patients with del(17p) in the M13-982 and MURANO studies in the interest of understanding these data in another context. These long-term data show the continued benefits of venetoclax in patients with del(17p) CLL. The trial was registered at www.clinicaltrials.gov as #NCT01889186.
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Affiliation(s)
| | - Eugen Tausch
- Division of CLL, Internal Medicine III, Ulm University, Ulm, Germany
| | - Andrew W. Roberts
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, and University of Melbourne, Melbourne, Australia
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Barbara Eichhorst
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University Hospital of Cologne, Cologne, Germany
| | - Peter Hillmen
- Leeds Teaching Hospitals, NHS Trust, Leeds, United Kingdom
| | | | - Johannes Schetelig
- Medical Clinic I, Department of Hematology, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Sebastian Böttcher
- Division of Internal Medicine, Medical Clinic III-Hematology, Oncology and Palliative Medicine, Rostock University Medical Center, Rostock, Germany
| | - Arnon P. Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | | | | | | | | | | | | | | | | | - William G. Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John F. Seymour
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, and University of Melbourne, Melbourne, Australia
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25
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Bajwa A, Habib A, Kittai AS. Treatment of Richter's Transformation with Novel Therapies. Curr Hematol Malig Rep 2024; 19:45-55. [PMID: 38194201 PMCID: PMC10894755 DOI: 10.1007/s11899-023-00721-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review presents recently published clinical trial data and ongoing investigations regarding the treatment of Richter's transformation (RT). RECENT FINDINGS Recently, numerous approaches have been investigated for the treatment of RT including: traditional chemoimmunotherapy regimens combined with targeted agents such as BTKi and BCL2i; immunotherapy combined with targeted agents; non-covalent BTKis; bispecific T cell engagers; and CART therapy. In addition, various novel targeted agents are currently being studied for the treatment of RT in phase 1 and 2 clinical trials. Standard of care treatment with chemoimmunotherapy for RT has limited efficacy in achieving durable remissions. Here, we review recent data on the use of combination treatments and targeted agents in RT. Although some progress has been made in the investigation to optimize treatment of RT, further study is needed to evaluate long term outcomes of recently published trials and test efficacy of upcoming novel agents.
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Affiliation(s)
- Amneet Bajwa
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Alma Habib
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Adam S Kittai
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA.
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Pham N, Coombs CC, O'Brien S. Are we closer to a standard of care for Richter's syndrome? Novel treatments on the horizon. Expert Rev Hematol 2024; 17:117-126. [PMID: 38693662 DOI: 10.1080/17474086.2024.2350528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/29/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The therapeutic landscape for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has significantly evolved over the past decade with dramatically improved outcomes with the introduction of targeted therapies. This unfortunately has not been the case for Richter transformation (RT), the histologic transformation to a more aggressive lymphoma, most typically diffuse large B-cell lymphoma (DLBCL). As such, RT continues to be one of the most challenging complications of CLL/SLL. Historically, RT has a poor response to treatment, with a minority reaching complete remission (CR) and overall survival (OS) being less than a year. AREAS COVERED The focus of this review is to discuss the effectiveness of commonly used regimens, and review existing data for emerging regimens being examined in ongoing clinical trials to improve prognosis and outcomes in patients with RT. Despite extensive efforts to optimize therapies for RT, there is still no generalized consensus on either first-line treatment regimens or regimens in the relapsed/refractory setting. RT continues to carry a high mortality rate without durable response to current therapeutic agents. EXPERT OPINION Ongoing and future research may identify novel treatment approaches that will eventually improve outcomes for patients with RT. The optimal care for RT patients is a clinical trial, when feasible.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/mortality
- Standard of Care
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Clinical Trials as Topic
- Molecular Targeted Therapy
- Treatment Outcome
- Disease Management
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Affiliation(s)
- Nghia Pham
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Catherine C Coombs
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Susan O'Brien
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
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27
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Ahn IE, Davids MS. Therapeutic targeting of apoptosis in chronic lymphocytic leukemia. Semin Hematol 2024; 61:109-118. [PMID: 38538512 DOI: 10.1053/j.seminhematol.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 06/09/2024]
Abstract
Therapeutic targeting of apoptosis with small molecule B-cell lymphoma 2 (BCL-2) inhibition with venetoclax is highly efficacious in CLL, leading to sustained deep responses, particularly among patients with treatment-naïve disease with favorable prognostic markers. Patients with unfavorable genetic characteristics such as TP53 aberration and unmutated IGHV may also derive durable benefits, but their remission duration after time-limited venetoclax-containing combination therapy is shorter, particularly in patients with relapsed/refractory disease. Emerging data indicate that the context of disease progression after initial treatment with venetoclax may define the success of re-treatment with venetoclax. Specifically, continuous venetoclax exposure may select for resistant disease due to genetic mechanisms such as BCL2 mutations and functional resistance mechanisms such as hyperphosphorylation of BCL-2 family proteins, which decrease the affinity of venetoclax binding to the target or lead to increased MCL-1 dependence and concomitant decrease in BCL-2 dependence. These patients may be best served by switching to a different class of targeted agents at the time of progression. In contrast, relapsed CLL that arises while being off therapy after a period of time-limited venetoclax-based regimens maintains sensitivity to re-treatment with venetoclax for the majority of patients. Novel strategies related to therapeutic targeting of apoptosis include next-generation BCL-2 inhibitors with improved potency and pharmacokinetic profiles, direct targeting of anti-apoptotic BH3 family proteins beyond BCL-2 such as MCL-1, and indirect targeting of MCL-1 through mechanisms such as small molecule cyclin-dependent kinase 9 inhibitors.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Apoptosis/drug effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/metabolism
- Sulfonamides/therapeutic use
- Sulfonamides/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Molecular Targeted Therapy/methods
- Drug Resistance, Neoplasm/drug effects
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Affiliation(s)
- Inhye E Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
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28
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Moia R, Gaidano G. Prognostication in chronic lymphocytic leukemia. Semin Hematol 2024; 61:83-90. [PMID: 38523019 DOI: 10.1053/j.seminhematol.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. CLL is a highly heterogeneous disease: some patients may never require therapy and others relapse several times after different therapeutic strategies. Therefore, in CLL, prognostic markers are essential to capture high-risk patients for different clinical endpoints including early treatment requirement, early progression after BTK or BCL2 inhibitors and Richter transformation. In early stage CLL, different biological and clinical biomarkers have been identified to predict time to treatment requirement that could be used to identify the most appropriate population for early intervention clinical trial. However, at the moment, the standard of care for early stage CLL remains watch & wait since no survival benefit has been identified in clinical trials with chemoimmunotherapy and with BTK inhibitors. In patients requiring treatment TP53 disruptions identify high-risk patients who benefit the most from long-term continuous therapy with BTKi. On the opposite side of the spectrum, IGHV mutated patients devoid of TP53 disruption benefit the most from fixed-duration therapy with venetoclax-obinutuzumab. In between, the highly heterogenous subgroup of patients with IGHV unmutated genes represents the group in which further efforts are needed to identify additional prognostic biomarkers aimed at selecting patients who can benefit from fixed-duration and patients who can benefit from long term BTKi therapy. In the context of the aggressive transformation of CLL, namely Richter syndrome, the clonal relationship to the CLL counterpart represents the strongest prognostic biomarker. Clonally related Richter syndrome still represents an unmet clinical need which requires further efforts to identify new therapeutic strategies.
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MESH Headings
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Humans
- Prognosis
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Mutation
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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29
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Lew TE, Bennett R, Lin VS, Whitechurch A, Handunnetti SM, Marlton P, Shen Y, Mulligan SP, Casan J, Blombery P, Tam CS, Roberts AW, Seymour JF, Thompson PA, Anderson MA. Venetoclax-rituximab is active in patients with BTKi-exposed CLL, but durable treatment-free remissions are uncommon. Blood Adv 2024; 8:1439-1443. [PMID: 38231032 PMCID: PMC10955641 DOI: 10.1182/bloodadvances.2023011327] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024] Open
Affiliation(s)
- Thomas E. Lew
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Rory Bennett
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Victor S. Lin
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Ashley Whitechurch
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Paula Marlton
- Department of Hematology, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yandong Shen
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Stephen P. Mulligan
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
- Department of Haematology and Flow Cytometry, Laverty Pathology, Sydney, NSW, Australia
| | - Joshua Casan
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Piers Blombery
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Andrew W. Roberts
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - John F. Seymour
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Philip A. Thompson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Mary A. Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC, Australia
- Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
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30
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Anderson MA, Walewska R, Hackett F, Kater AP, Montegaard J, O'Brien S, Seymour JF, Smith M, Stilgenbauer S, Whitechurch A, Brown JR. Venetoclax Initiation in Chronic Lymphocytic Leukemia: International Insights and Innovative Approaches for Optimal Patient Care. Cancers (Basel) 2024; 16:980. [PMID: 38473342 DOI: 10.3390/cancers16050980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 03/14/2024] Open
Abstract
Venetoclax, a highly selective, oral B-cell lymphoma 2 inhibitor, provides a robust targeted-therapy option for the treatment of chronic lymphocytic leukemia (CLL), including patients with high-risk del(17p)/mutated-TP53 and immunoglobulin heavy variable region unmutated CLL and those refractory to chemoimmunotherapy across all age groups. Due to the potent pro-apoptotic effect of venetoclax, treatment initiation carries a risk of tumor lysis syndrome (TLS). Prompt and appropriate management is needed to limit clinical TLS, which may entail serious adverse events and death. Venetoclax ramp-up involves gradual, stepwise increases in daily venetoclax dosing from 20 mg to 400 mg (target dose) over 5 weeks; adherence to on-label scheduling provides a tumor debulking phase, reducing the risk of TLS. The key components of safe venetoclax therapy involve assessment (radiographic evaluation and baseline blood chemistry), preparation (adequate hydration), and initiation (blood chemistry monitoring). In addition to summarizing the evidence for venetoclax's efficacy and safety, this review uses hypothetical patient scenarios based on risk level for TLS (high, medium, low) to share the authors' clinical experience with venetoclax initiation and present global approaches utilized in various treatment settings. These hypothetical scenarios highlight the importance of a multidisciplinary approach and shared decision-making, outlining best practices for venetoclax initiation and overall optimal treatment strategies in patients with CLL.
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Affiliation(s)
- Mary Ann Anderson
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC 3000, Australia
- Division of Blood Cells and Blood Cancers, The Walter and Eliza Hall Institute, Melbourne, VIC 3000, Australia
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Renata Walewska
- University Hospitals Dorset, NHS Foundation Trust, Bournemouth BH7 7DW, UK
| | - Fidelma Hackett
- Cancer Services Directorate, University Hospital Limerick UL Hospitals Group, St. Nessan's Road, V94 F858 Limerick, Ireland
| | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, 1081 HV Amsterdam, The Netherlands
| | - Josie Montegaard
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA 92868, USA
| | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3000, Australia
| | - Matthew Smith
- Department of Haematology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield S44 5BL, UK
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, 89081 Ulm, Germany
| | - Ashley Whitechurch
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC 3000, Australia
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
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31
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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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32
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Bennett R, Seymour JF. Update on the management of relapsed/refractory chronic lymphocytic leukemia. Blood Cancer J 2024; 14:33. [PMID: 38378673 PMCID: PMC10879527 DOI: 10.1038/s41408-024-01001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
Chronic lymphocytic leukemia (CLL) predominantly affects older adults, characterized by a relapsing and remitting pattern with sequential treatments available for many patients. Identification of progressive/relapsed CLL should prompt close monitoring and early discussion about the next therapies when treatment indications are present. The intervening period represents an opportunity to optimize patient health, including establishing adequate vaccination and surveillance for second primary malignancies, and treating non-CLL-related comorbidities which may impact well-being and CLL therapy. We now see patients with relapsed/refractory (RR) CLL in the clinic who have been previously treated with chemoimmunotherapy (CIT) and/or one or more novel therapies. Continuous covalent inhibitors of Bruton's tyrosine kinase (cBTKi) and fixed-duration venetoclax (Ven)-anti-CD20 monoclonal antibody (mAb) are preferred over CIT given the survival advantages associated with these therapies, although have never been evaluated head-to-head. While both classes are effective for RR CLL, potential side effects and the logistics of administration differ. Few randomized data demonstrate the sequential use of cBTKi and fixed-duration Ven-anti-CD20 mAb; however, they may be used in either sequence. Newer non-covalent BTKi, active against BTK C481 resistance mutations emerging with continuous cBTKi exposure, and novel approaches such as BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell therapies demonstrate impressive efficacy. In this review of RR CLL we explore relevant investigations, consideration of broader CLL- and non-CLL-related health needs, and evidence for efficacy and safety of B-cell receptor inhibitors and Ven, including available data to support drug sequencing or switching. We describe novel approaches to RR CLL, including rechallenging with fixed-duration therapies, allogeneic stem cell transplant indications in the novel therapy era, and highlight early data supporting the use of T-cell directing therapies and novel drug targets.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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Saburi M, Nishikawa T, Miyazaki Y, Kohno K, Sakata M, Okuhiro K, Nakayama T, Ohtsuka E, Ogata M. Real-world outcomes of venetoclax and rituximab for chronic lymphocytic leukemia/small lymphocytic lymphoma: A retrospective analysis of nine Japanese cases. J Clin Exp Hematop 2024; 64:152-155. [PMID: 38925975 PMCID: PMC11303959 DOI: 10.3960/jslrt.24014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 06/28/2024] Open
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35
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Ujjani C. Dual-targeted regimens for the frontline treatment of CLL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:421-426. [PMID: 38066921 PMCID: PMC10726988 DOI: 10.1182/hematology.2023000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The treatment landscape of chronic lymphocytic leukemia (CLL) has evolved considerably over the past decade due to the development of effective novel agents with varying mechanisms of action, including Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL2) inhibitors. Extrapolating upon the success of anti-CD20-directed chemoimmunotherapy, a dual-targeted approach has been explored in treatment-naive patients with CLL. Anti-CD20 monoclonal antibody combinations with BTK inhibitors as well as BCL2 inhibitors have demonstrated superiority over traditional cytotoxic chemoimmunotherapy regimens such as fludarabine, cyclophosphamide, and rituximab; bendamustine-rituximab; and obinutuzumab-chlorambucil. Impressive clinical benefit is seen in both younger and older patients, those with comorbidities, and, most importantly, those with poor prognostic features. Given this success, combinations of BTK inhibitors and venetoclax have been explored in clinical trials. These dual-targeted regimens provide remarkable efficacy while allowing for an all-oral approach and fixed duration of treatment. Current investigations under way are evaluating the utility of a triplet approach with the addition of obinutuzumab in comparison to a doublet approach.
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Affiliation(s)
- Chaitra Ujjani
- Fred Hutchinson Cancer Center, University of Washington, Division of Medical Oncology, Seattle, WA
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36
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Autore F, Innocenti I, Reda G, Visentin A, Vitale C, Piciocchi A, Fresa A, Leone MMA, Farina L, Quaresmini G, Baratè C, Giordano A, Ferrari A, Angeletti I, De Paolis MR, Malerba L, Chiurazzi F, Loseto G, Catania G, Sportoletti P, Scortechini I, Moia R, Gentile M, Rigolin GM, Mattiello V, Gattei V, Coscia M, Trentin L, Foà R, Cuneo A, Laurenti L. Lymphadenopathy as a predictor of progression during venetoclax treatment in chronic lymphocytic leukemia. A campus chronic lymphocytic leukemia study. Hematol Oncol 2023; 41:877-883. [PMID: 37392141 DOI: 10.1002/hon.3199] [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: 04/07/2023] [Revised: 05/30/2023] [Accepted: 06/17/2023] [Indexed: 07/03/2023]
Abstract
Clinical or biological parameters useful to predict progression during treatment in real-life setting with ibrutinib, idelalisib and venetoclax in relapsed/refractory chronic lymphocytic leukemia (CLL) are still debated. We conducted a multi-center retrospective study on CLL patients treated with ibrutinib and/or idelalisib who were switched to venetoclax for progression or due to adverse events to identify any clinical and/or biological parameters useful to predict progression during treatment with venetoclax. Of all the 128 evaluable patients, 81 had received ibrutinib prior to switching to venetoclax, 35 had received idelalisib and 12 both. When comparing the three subgroups, we did not notice any statistical difference in terms of clinical or biological features. No variable at baseline and at different time points during the follow-up (at 6, 12, 18 and 24 months) was found to predict progression nor to have significance for Progression Free Survival (PFS) in the ibrutinib group and in the idelalisib group and in subgroups according to the line of treatment. Analyzing the data of the venetoclax treatment, after a median follow up of 14.3 months, median PFS was not reached and estimated 3-year PFS was 54%. Of the 128 patients treated with venetoclax, 28 (22%) experienced progressive disease. At multivariate analysis for predictive factors for progression, lymph node diameter >56.5 mm before starting treatment emerged as an independent risk factor for progression. The lymph node predictive role for progression during venetoclax treatment could be a new parameter that deserves to be investigate in future studies.
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Affiliation(s)
- Francesco Autore
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Idanna Innocenti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | - Gianluigi Reda
- Fondazione IRCCS Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | - Candida Vitale
- A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Alberto Fresa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Lucia Farina
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | | | - Angela Ferrari
- Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy
| | | | | | - Lara Malerba
- A.O. Ospedali San Salvatore di Pesaro, Pesaro, Italy
| | | | | | | | - Paolo Sportoletti
- Centro di Ricerca Emato-Oncologica (CREO), Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | | | - Riccardo Moia
- Università del Piemonte Orientale, A.O.U. Maggiore della Carità, Novara, Italy
| | - Massimo Gentile
- AO di Cosenza, Presidio Ospedaliero Annunziata, Cosenza, Italy
| | | | | | - Valter Gattei
- Centro di Riferimento Oncologico di Aviano IRCCS, Aviano, Italy
| | - Marta Coscia
- A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Robin Foà
- Policlinico Umberto I, Università Sapienza, Roma, Italy
| | - Antonio Cuneo
- A.O.U. Arcispedale S. Anna, Università di Ferrara, Ferrara, Italy
| | - Luca Laurenti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
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Parry EM, Roulland S, Okosun J. DLBCL arising from indolent lymphomas: How are they different? Semin Hematol 2023; 60:277-284. [PMID: 38072721 DOI: 10.1053/j.seminhematol.2023.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 03/12/2024]
Abstract
Transformation to diffuse large B-cell lymphoma (DLBCL) is a recognized, but unpredictable, clinical inflection point in the natural history of indolent lymphomas. Large retrospective studies highlight a wide variability in the incidence of transformation across the indolent lymphomas and the adverse outcomes associated with transformed lymphomas. Opportunities to dissect the biology of transformed indolent lymphomas have arisen with evolving technologies and unique tissue collections enabling a growing appreciation, particularly, of their genetic basis, how they relate to the preceding indolent lymphomas and the comparative biology with de novo DLBCL. This review summarizes our current understanding of both the clinical and biological aspects of transformed lymphomas and the outstanding questions that remain.
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Affiliation(s)
- Erin M Parry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sandrine Roulland
- Aix-Marseille University, CNRS, INSERM, Centre d'Immunologie de Marseille-Luminy, Marseille, France
| | - Jessica Okosun
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK; Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK.
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Abstract
PURPOSE OF REVIEW There have been significant advances in the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL) over the past two decades. However, the intention of treatment remains control of the disease and delay of progression rather than a cure which remains largely elusive. Considering that CLL is mostly seen in older patients, there are multiple factors that play a role in the selection of CLL beyond the frontline treatment. Here, we review the concept of relapsed CLL, factors that predispose to relapse, and therapeutic options available to this patient population. We also review investigational therapies and provide a framework for selection of therapies in this setting. RECENT FINDINGS Targeted therapies with continuous BTK inhibitors (BTKi) or fixed duration venetoclax plus anti-CD20 monoclonal antibody therapy have established superiority over chemoimmunotherapy in relapsed CLL and have become the preferred standard of care treatment. The second-generation more selective BTK inhibitors (acalabrutinib and zanubrutinib) have shown improved safety profile compared to ibrutinib. However, resistance to the covalent BTK inhibitors may emerge and is commonly associated with mutations in BTK or other downstream enzymes. The novel non-covalent BTK inhibitors such as pirtobrutinib (Loxo-305) and nemtabrutinib (ARQ 531) are showing promising activities for relapsed CLL refractory to prior covalent BTKi. Other novel therapies such as chimeric antigen receptor (CAR) T cell therapy have also shown significant activities for relapsed and refractory CLL. Measurable residual disease (MRD) assessment has a growing importance in venetoclax-based limited-duration therapy and there is mounting evidence that MRD negativity improves outcomes. However, it remains to be seen if this will become an established clinically significant endpoint. Further, the optimal sequence of various treatment options remains to be determined. Patients with relapsed CLL now have more options for the treatment of the disease. The choice of therapy is best individualized especially in the absence of direct comparisons of targeted therapies, and the coming years will bring more data on the best sequence of use of the therapeutic agents.
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Affiliation(s)
- Oluwatobi Odetola
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA.
| | - Shuo Ma
- Robert H. Lurie Comprehensive Cancer Center, Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 805, Chicago, IL, 60611, USA
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39
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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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40
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Izutsu K, Yamamoto K, Kato K, Ishikawa T, Fukuhara N, Terui Y, Choi I, Okubo S, Ogawa N, Sakai M, Nishimura Y, Chyla B, Sun Y, Maruyama D. Measurable residual disease in Japanese patients with relapsed or refractory chronic lymphocytic leukemia treated with venetoclax. Int J Hematol 2023; 118:526-528. [PMID: 37581752 PMCID: PMC10522736 DOI: 10.1007/s12185-023-03646-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/13/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Koji Izutsu
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan.
| | - Kazuhito Yamamoto
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Aichi, Japan
| | - Koji Kato
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Takayuki Ishikawa
- Department of Hematology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Noriko Fukuhara
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yasuhito Terui
- Department of Hematology Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
- Department of Hematology, Saitama Medical University Hospital, Saitama, Japan
| | - Ilseung Choi
- Department of Hematology, National Hospital Organization, Kyushu Cancer Center, Fukuoka, Japan
| | | | | | | | | | | | - Yan Sun
- AbbVie, Inc, North Chicago, IL, USA
| | - Dai Maruyama
- Department of Hematology, National Cancer Center Hospital, Tokyo, Japan
- Department of Hematology Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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41
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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42
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Rigolin GM, Traversa A, Caputo V, Del Giudice I, Bardi A, Saccenti E, Raponi S, Ilari C, Cafforio L, Giovannetti A, Pizzuti A, Guarini A, Foà R, Cuneo A. Additional lesions identified by genomic microarrays are associated with an inferior outcome in low-risk chronic lymphocytic leukaemia patients. Br J Haematol 2023; 202:953-959. [PMID: 37357817 DOI: 10.1111/bjh.18946] [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: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/27/2023]
Abstract
We explored the relevance of genomic microarrays (GM) in the refinement of prognosis in newly diagnosed low-risk chronic lymphocytic leukaemia (CLL) patients as defined by isolated del(13q) or no lesions by a standard 4 probe fluorescence in situ hybridization (FISH) analysis. Compared to FISH, additional lesions were detected by GM in 27 of the 119 patients (22.7%). The concordance rate between FISH and GM was 87.4%. Discordant results between cytogenetic banding analysis (CBA) and GM were observed in 45/119 cases (37.8%) and were mainly due to the intrinsic characteristics of each technique. The presence of additional lesions by GM was associated with age > 65 years (p = 0.047), advanced Binet stage (p = 0.001), CLL-IPI score (p < 0.001), a complex karyotype (p = 0.004) and a worse time-to-first treatment in multivariate analysis (p = 0.009). Additional lesions by GM were also significantly associated with a worse time-to-first treatment in the subset of patients with wild-type TP53 and mutated IGHV (p = 0.025). In CLL patients with low-risk features, the presence of additional lesions identified by GM helps to identify a subset of patients with a worse outcome that could be proposed for a risk-adapted follow-up and for early treatment including targeted agents within clinical trials.
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Affiliation(s)
| | - Alice Traversa
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Viviana Caputo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonella Bardi
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
| | - Elena Saccenti
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
| | - Sara Raponi
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Caterina Ilari
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Luciana Cafforio
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
- GenomeUp S.r.l., Rome, Italy
| | - Agnese Giovannetti
- Clinical Genomics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, S. Giovanni Rotondo, Italy
| | - Antonio Pizzuti
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Anna Guarini
- Department of Molecular Medicine, Sapienza University, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
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43
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Anderson MA, Bennett R, Badoux X, Best G, Chia N, Cochrane T, Cull G, Crassini K, Harrup R, Jackson S, Kuss B, Lasica M, Lew TE, Marlton P, Opat S, Palfreyman E, Polizzotto MN, Ratnasingam S, Seymour JF, Soosapilla A, Talaulikar D, Tam CS, Weinkove R, Wight J, Mulligan SP. Chronic lymphocytic leukaemia Australasian consensus practice statement. Intern Med J 2023; 53:1678-1691. [PMID: 37743239 DOI: 10.1111/imj.16207] [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: 11/30/2022] [Accepted: 07/30/2023] [Indexed: 09/26/2023]
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common haematological malignancy in Australia and New Zealand (ANZ). Considerable changes to diagnostic and management algorithms have occurred within the last decade. The availability of next-generation sequencing and measurable residual disease assessment by flow cytometry allow for advanced prognostication and response assessments. Novel therapies, including inhibitors of Bruton's tyrosine kinase (BTKi) and B-cell lymphoma 2 (BCL2) inhibitors, have transformed the treatment landscape for both treatment-naïve and relapsed/refractory disease, particularly for patients with high-risk genetic aberrations. Recommendations regarding appropriate supportive management continue to evolve, and special considerations are required for patients with CLL with respect to the global SARS-CoV-2 pandemic. The unique funding and treatment environments in Australasia highlight the need for specific local guidance with respect to the investigation and management of CLL. This consensus practice statement was developed by a broadly representative group of ANZ experts in CLL with endorsement by peak haematology bodies, with a view to providing this standardised guidance.
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Affiliation(s)
- Mary A Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rory Bennett
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Xavier Badoux
- St George Hospital, Sydney, New South Wales, Australia
| | - Giles Best
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Nicole Chia
- Genomic Diagnostics, Healius Pathology, Brisbane, Queensland, Australia
| | - Tara Cochrane
- Gold Coast University Hospital, Griffith University, Gold Coast, Queensland, Australia
| | - Gavin Cull
- Sir Charles Gairdner Hospital, PathWest Laboratory Medicine and University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Crassini
- Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Rosemary Harrup
- Cancer and Blood Services Royal Hobart Hospital, Hobart, Tasmania, Australia
- Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharon Jackson
- Te Whatu Ora health New Zealand Counties Manukau, Auckland, New Zealand
| | - Bryone Kuss
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Masa Lasica
- St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Thomas E Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Stephen Opat
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Emma Palfreyman
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Mark N Polizzotto
- Department of Clinical Haematology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Clinical Hub for Interventional Research, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sumita Ratnasingam
- St John of God Hospital Geelong, Geelong, Victoria, Australia
- University Hospital Geelong, Geelong, Victoria, Australia
- School of Medicine, Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
| | - John F Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Asha Soosapilla
- Flow Cytometry, Healius Pathology, Sydney, New South Wales, Australia
| | - Dipti Talaulikar
- Department of Diagnostic Genomics, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Department of Haematology, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Constantine S Tam
- Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Robert Weinkove
- Te Rerenga Ora Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Joel Wight
- Department of Haematology and Bone Marrow Transplantation, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, School of Medicine, Townsville, Queensland, Australia
| | - Stephen P Mulligan
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Healius Pathology, Sydney, New South Wales, Australia
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44
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Islam P. Current Treatment Options in Relapsed and Refractory Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: a Review. Curr Treat Options Oncol 2023; 24:1259-1273. [PMID: 37407887 DOI: 10.1007/s11864-023-01112-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 07/07/2023]
Abstract
OPINION STATEMENT Treatment of relapsed and refractory (R/R) chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) has changed dramatically over the past decade due to the development of oral targeted agents in several therapeutic classes, including BTK inhibitors (such as ibrutinib, acalabrutinib, zanubrutinib, and the non-covalent BTK inhibitor pirtobrutinib), the first in class BCL2 inhibitor venetoclax, PI3K inhibitors (idelalisib and duvelisib), and monoclonal antibodies in monotherapy and in combination. My approach to treatment of the R/R patient draws heavily on prior therapies, such that a patient with no exposure to prior novel therapies would be offered either a BTK or BCL2-based regimen, whereas patients with prior BTK inhibitor exposure would likely receive a BCL2 inhibitor and vice versa. For patients who are intolerant to a BTK inhibitor but are otherwise responding, an alternate BTK inhibitor may be considered. For those patients who have received a fixed-duration BCL2 inhibitor-based regimen and have maintained a response for greater than 12-24 months, re-treatment with a BCL2 inhibitor-based regimen at progression may be considered based on limited data, recognizing that robust prospective clinical trials are lacking in this space. For those patients who are "double refractory" and have progressed on both a BTK inhibitor and a BCL2 inhibitor-based regimen, clinical trials are strongly preferred. In absence of a clinical trial, these patients can be challenged with PI3K inhibitors, though responses are usually not durable, and toxicity is high. Combination cytotoxic chemotherapy with novel agents, allogeneic hematopoietic stem cell transplant, and cellular therapy may be considered for very high-risk populations, such as patients with Richter's transformation, though novel approaches are urgently needed and clinical trial enrollment is highly encouraged.
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Affiliation(s)
- Prioty Islam
- Memorial Sloan Kettering Cancer Center, 530 E 74th St, New York, NY, 10021, USA.
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45
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Visentin A, Mauro FR, Scarfò L, Gentile M, Farina L, Reda G, Ferrarini I, Proietti G, Derenzini E, Cibien F, Vitale C, Sanna A, Pietrasanta D, Marchetti M, Murru R, Rigolin GM, Sportoletti P, Trimarco V, Cavarretta CA, Angotzi F, Cellini A, Ruocco V, Zatta I, Laurenti L, Molica S, Coscia M, Ghia P, Foà R, Cuneo A, Trentin L. Continuous venetoclax in treatment-naive TP53 disrupted patients with chronic lymphocytic leukemia: A chronic lymphocytic leukemia campus study. Am J Hematol 2023; 98:E237-E240. [PMID: 37382471 DOI: 10.1002/ajh.27009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Lydia Scarfò
- Strategic Research Program on CLL, Università Vita-salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Gentile
- Hematology Unit, Azienda Ospedaliera of Cosenza, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Lucia Farina
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | - Isacco Ferrarini
- Department of Engineering for Innovation Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Giulia Proietti
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Enrico Derenzini
- Divisions of Haemato-oncology, Haematology Programme, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Candida Vitale
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, AOU Careggi, Florence, Italy
| | - Daniela Pietrasanta
- Division of Hematology, A.O. SS Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Monia Marchetti
- Division of Hematology, A.O. SS Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco, ARNAS G. Brotzu, Cagliari, Italy
| | - Gian Matteo Rigolin
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Paolo Sportoletti
- Institute of Hematology and Center for Hemato-Oncology Research, University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Valentina Trimarco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Chiara Adele Cavarretta
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesco Angotzi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Alessandro Cellini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Valeria Ruocco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Ivan Zatta
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Luca Laurenti
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | | | - Marta Coscia
- Department of Molecular Biotechnology and Health Sciences, University of Torino and Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Paolo Ghia
- Strategic Research Program on CLL, Università Vita-salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, 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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46
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Nguyen PC, Nguyen V, Baldwin K, Kankanige Y, Blombery P, Came N, Westerman DA. Computational flow cytometry provides accurate assessment of measurable residual disease in chronic lymphocytic leukaemia. Br J Haematol 2023; 202:760-770. [PMID: 37052611 DOI: 10.1111/bjh.18802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/14/2023]
Abstract
Undetectable measurable residual disease (MRD) is associated with favourable clinical outcomes in chronic lymphocytic leukaemia (CLL). While assessment is commonly performed using multiparameter flow cytometry (MFC), this approach is associated with limitations including user bias and expertise that may not be widely available. Implementation of unsupervised clustering algorithms in the laboratory can address these limitations and have not been previously reported in a systematic quantitative manner. We developed a computational pipeline to assess CLL MRD using FlowSOM. In the training step, a self-organising map was generated with nodes representing the full breadth of normal immature and mature B cells along with disease immunophenotypes. This map was used to detect MRD in multiple validation cohorts containing a total of 456 samples. This included an evaluation of atypical CLL cases and samples collected from two different laboratories. Computational MRD showed high correlation with expert analysis (Pearson's r > 0.99 for typical CLL). Binary classification of typical CLL samples as either MRD positive or negative demonstrated high concordance (>98%). Interestingly, computational MRD detected disease in a small number of atypical CLL cases in which MRD was not detected by expert analysis. These results demonstrate the feasibility and value of automated MFC analysis in a diagnostic laboratory.
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Affiliation(s)
- Phillip C Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Vuong Nguyen
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Kylie Baldwin
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Yamuna Kankanige
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Piers Blombery
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Neil Came
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - David A Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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47
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Riva G, Luppi M, Tagliafico E. From gating to computational flow cytometry: Exploiting artificial intelligence for MRD diagnostics. Br J Haematol 2023; 202:715-717. [PMID: 37092558 DOI: 10.1111/bjh.18833] [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: 04/14/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
The era of AI-based methods to improve flow cytometry diagnostics in haematology is now at the beginning. The study by Nguyen and colleagues explored an emerging machine learning approach to assess phenotypic MRD in chronic lymphocytic leukaemia patients, showing that such AI-driven computational analysis may represent a robust and feasible tool for advanced diagnostics of haematological malignancies. Commentary on: Nguyen et al. Computational flow cytometry provides accurate assessment of measurable residual disease in chronic lymphocytic leukaemia. Br J Haematol 2023;202:760-770.
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Affiliation(s)
- Giovanni Riva
- Diagnostic Hematology and Clinical Genomics Laboratory, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Modena, Modena, Italy
| | - Enrico Tagliafico
- Diagnostic Hematology and Clinical Genomics Laboratory, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, Modena, Italy
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48
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Bennett R, Anderson MA, Seymour JF. Unresolved questions in selection of therapies for treatment-naïve chronic lymphocytic leukemia. J Hematol Oncol 2023; 16:72. [PMID: 37422670 PMCID: PMC10329329 DOI: 10.1186/s13045-023-01469-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The treatment landscape for chronic lymphocytic leukemia (CLL) continues to undergo considerable evolution. Optimal selection of initial therapy from multiple effective options provides a major challenge for clinicians, who need to consider both disease and patient factors in conjunction with a view to sequencing available therapies in event of disease relapse. REVIEW We explore the most topical clinically relevant unresolved questions through discussion of important available pertinent literature and propose expert opinion based on these data. (1) Shrinking role of chemoimmunotherapy (CIT); while novel therapies are generally superior, we highlight the utility of FCR for IGHV-mutated CLL. (2) Choosing between inhibitors of Bruton's tyrosine kinase (BTKi); while efficacy between agents is likely similar there are important differences in toxicity profiles, including the incidence of cardiac arrhythmia and hypertension. (3) BTKi with or without anti-CD20 monoclonal antibodies (mAb); while obinutuzumab-acalabrutinib (AO) may confer superior progression-free survival to acalabrutinib (Acala), this is not true of rituximab (Ritux) to ibrutinib (Ib)-we highlight that potential for increased side effects should be carefully considered. (4) Continuous BTKi versus time-limited venetoclax-obinutuzumab (VenO); we propose that venetoclax (Ven)-based therapy is generally preferable to BTKi with exception of TP53 aberrant disease. (5) BTKi-Ven versus VenO as preferred time-limited therapy; we discuss comparable efficacies and the concerns about simultaneous 1L exposure to both BTKi and Ven drug classes. (6) Utility of triplet therapy (BTKi-Ven-antiCD20 mAb) versus VenO; similar rates of complete response are observed yet with greater potential for adverse events. (7) Optimal therapy for TP53 aberrant CLL; while limited data are available, there are likely effective novel therapy combinations for TP53 aberrant disease including BTKi, BTKi-Ven ± antiCD20 mAb. CONCLUSION Frontline therapy for CLL should be selected based on efficacy considering the patient specific biologic profile of their disease and potential toxicities, considering patient comorbidities and preferences. With the present paradigm of sequencing effective agents, 1L combinations of novel therapies should be used with caution in view of potential adverse events and theoretical resistance mechanism concerns in the absence of compelling randomized data to support augmented efficacy.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, 1G, Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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49
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Hengeveld PJ, Schilperoord-Vermeulen J, van der Klift MY, Dubois JMN, Kolijn PM, Kavelaars FG, Rijken M, Dobber JA, Nasserinejad K, Kersting S, Westerweel PE, Kater AP, Langerak AW, Levin MD. Early-stage measurable residual disease dynamics and IGHV repertoire reconstitution during venetoclax and obinutuzumab treatment in chronic lymphocytic leukemia. Blood Cancer J 2023; 13:102. [PMID: 37400508 DOI: 10.1038/s41408-023-00870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- P J Hengeveld
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
- Department of Immunology, Erasmus MC, Rotterdam, the Netherlands
| | | | | | - J M N Dubois
- Department of Hematology and Experimental Immunology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - P M Kolijn
- Department of Immunology, Erasmus MC, Rotterdam, the Netherlands
| | - F G Kavelaars
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - M Rijken
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J A Dobber
- Department of Hematology and Experimental Immunology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - K Nasserinejad
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - S Kersting
- Department of Hematology, Haga Hospital, The Hague, The Netherlands
| | - P E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - A P Kater
- Department of Hematology and Experimental Immunology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - A W Langerak
- Department of Immunology, Erasmus MC, Rotterdam, the Netherlands
| | - M-D Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands.
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50
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Guarana M, Nucci M. Infections in patients with chronic lymphocytic leukemia. Hematol Transfus Cell Ther 2023; 45:387-393. [PMID: 37407362 PMCID: PMC10499585 DOI: 10.1016/j.htct.2023.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 02/15/2023] [Accepted: 05/28/2023] [Indexed: 07/07/2023] Open
Abstract
INTRODUCTION Infection is a major complication in patients with chronic lymphocytic leukemia (CLL). Newly diagnosed patients are at high risk of developing infection caused by encapsulated bacteria, such as Streptococcus pneumoniae and Haemophylus influenzae. METHOD AND RESULTS However, once treatment is initiated, the spectrum of pathogens causing infection broadens, depending on the treatment regimens. With disease progression, cumulative immunosuppression occurs as a consequence of multiple treatment lines and the risk of infection further increases. On the other hand, the use of targeted therapies in the treatment of CLL have brought new risks of infection, with an increased incidence of invasive fungal diseases, particularly aspergillosis, in patients receiving Bruton kinase inhibitors. CONCLUSION In this article, we review the epidemiology of infection in patients with CLL, taking into account the treatment regimen, and briefly discuss the management of infection.
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Affiliation(s)
- Mariana Guarana
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Marcio Nucci
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil; Grupo Oncoclinicas, Rio de Janeiro, RJ, Brazil.
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