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Joffe E, Ariela Arad N, Bairey O, Fineman R, Ruchlemer R, Rahimi-Levene N, Shvidel L, Greenbaum U, Aviv A, Tadmor T, Braester A, Goldschmidt N, Polliack A, Herishanu Y. Persistently low lymphocyte counts after FCR therapy for chronic lymphocytic leukemia are associated with longer overall survival. Hematol Oncol 2017. [PMID: 28639416 DOI: 10.1002/hon.2444] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Decreased absolute lymphocyte counts (ALCs) following frontline therapy for chronic lymphocytic leukemia may be associated with disease control, even in patients without evidence of minimal residual disease. We studied the prognostic significance of ALCs during the first year following treatment with fludarabine, cyclophosphamide, and rituximab (FCR). We evaluated 99 patients who achieved a partial response without lymphocytosis (<4.0 × 103 cells/μL) or better after FCR. Absolute lymphocyte counts were recorded at 3-, 6-, 9-, and 12-month posttreatment and correlated with overall survival (OS) and event-free survival (EFS). For each time point, analyses were limited to patients without lymphocytosis, so as to avoid possible biases from undocumented disease progressions. Lymphopenia (ALC < 1.0 × 103 cells/μL) at 3 m after FCR (69% of patients n = 68), was associated with a longer OS (5y OS 91% vs 64%, P = .001), as were ALC ≤ 2 × 103 cells/μL at 6 m (5y OS 85% vs 48%, P = .004) and ALC ≤ 1.8 × 103 cells/μL at 9 m (5y OS 93% vs 54%, P = .009). A normal-range ALC (≤4 × 103 cells/μL) at 12 m was also associated with a 91% 5y OS. Higher ALCs (but without lymphocytosis) were associated with shorter EFS (median EFS 27 months for ALC > 1.8 vs not reached for ALC ≤ 0.7 at 9 months, P < .0001). In conclusion, lower ALC levels in the first few months following frontline FCR therapy were associated with longer OS and EFS. Possible explanations may be that lower ALCs reflect deeper clonal suppression or protracted Treg depletion. Absolute lymphocyte count levels may be a cheap and widely available prognostic marker, though the added value for clinical practice is the minimal residual disease era needs to be explored.
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Affiliation(s)
- Erel Joffe
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Tel Aviv, Israel.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - N Ariela Arad
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
| | - Osnat Bairey
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Tel Aviv, Israel.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Riva Fineman
- Department of Hematology, Rambam Medical Center, Haifa, Israel
| | - Rosa Ruchlemer
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Naomi Rahimi-Levene
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Tel Aviv, Israel.,Hematology Institute, Assaf Harofe Medical Center, Zerifin, Israel
| | - Lev Shvidel
- Department of Hematology, Kaplan Medical Center, Rehovot, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Uri Greenbaum
- Soroka Medical Center, Beer Sheba and Ben-Gurion University, Beer Sheva, Israel
| | - Ariel Aviv
- Department of Hematology, Emek Medical Center, Afula, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | - Andrei Braester
- Department of Hematology, Western Galilee Hospital, Nahariya, Israel
| | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Aaron Polliack
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Yair Herishanu
- Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv, Tel Aviv, Israel.,The Hematology Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Nimmanapalli R, Lyu MA, Du M, Keating MJ, Rosenblum MG, Gandhi V. The growth factor fusion construct containing B-lymphocyte stimulator (BLyS) and the toxin rGel induces apoptosis specifically in BAFF-R-positive CLL cells. Blood 2006; 109:2557-64. [PMID: 17119117 DOI: 10.1182/blood-2006-08-042424] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The cytokine B lymphocyte stimulator (BLyS) mediates its effect through cell-surface receptors BAFF-R, TACI, and BCMA. BLyS receptors are expressed only on B cells and not present in other normal cells including normal T lymphocytes. Chronic lymphocytic leukemia (CLL) is a B-cell disease and CLL lymphocytes express BLyS receptors. Gelonin, a type 1 ribosome-inactivating toxin, lacks cell membrane binding domain and hence is nontoxic to intact cells. We generated a construct of recombinant gelonin (rGel) fused to BLyS to specifically target quiescent B-CLL lymphocytes. The construct rGel/BLyS specifically binds and internalizes through BAFF-R into CD19(+) B-CLL lymphocytes and induces apoptosis at nanomolar concentrations. In contrast, rGel alone was not able to internalize into these leukemic lymphocytes. Mechanistically, the rGel/BLyS construct inhibits protein synthesis with an IC(50) of less than 3 nM compared with more than 5000 nM for rGel toxin alone. This rGel/BLyS-mediated decrease in protein synthesis was associated with a decline in short-lived proteins such as MCL-1 and XIAP, the 2 survival proteins in B-CLL. There was a strong relationship between a decrease in these proteins and the cleavage of PARP, a hallmark feature of apoptosis. Taken together, these data suggest that the rGel/BLyS fusion toxin may have potential therapeutic efficacy for B-CLL patients.
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MESH Headings
- Antigens, CD19/genetics
- Antigens, CD19/metabolism
- Apoptosis/drug effects
- B-Cell Activating Factor/genetics
- B-Cell Activating Factor/metabolism
- B-Cell Activating Factor/pharmacology
- B-Cell Activation Factor Receptor/genetics
- B-Cell Activation Factor Receptor/metabolism
- Cells, Cultured
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphocytes/drug effects
- Lymphocytes/metabolism
- Plant Proteins/genetics
- Plant Proteins/metabolism
- Plant Proteins/pharmacology
- RNA/biosynthesis
- Recombinant Fusion Proteins/genetics
- Recombinant Fusion Proteins/metabolism
- Recombinant Fusion Proteins/pharmacology
- Ribosome Inactivating Proteins, Type 1
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Affiliation(s)
- Ramadevi Nimmanapalli
- Department of Experimental Therapeutics, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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3
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Caballero D, García-Marco JA, Martino R, Mateos V, Ribera JM, Sarrá J, León A, Sanz G, de la Serna J, Cabrera R, González M, Sierra J, San Miguel J. Allogeneic Transplant with Reduced Intensity Conditioning Regimens may Overcome the Poor Prognosis of B-Cell Chronic Lymphocytic Leukemia with Unmutated Immunoglobulin Variable Heavy-Chain Gene and Chromosomal Abnormalities (11q− and 17p−). Clin Cancer Res 2005; 11:7757-63. [PMID: 16278397 DOI: 10.1158/1078-0432.ccr-05-0941] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the efficacy of reduced intensity conditioning (RIC) allogeneic transplant in 30 patients with poor-prognosis chronic lymphocytic leukemia (CLL) and/or high-risk molecular/cytogenetic characteristics. EXPERIMENTAL DESIGN Eighty-three percent of patients had active disease at the moment of transplant. That is, 14 of the 23 patients analyzed (60%) had unmutated immunoglobulin variable heavy-chain gene (IgV(H)) status; 8 of 25 patients (32%) had 11q-, with four of them also displaying unmutated IgV(H); and six (24%) had 17p- (five were also unmutated). RESULTS After a median follow-up of 47.3 months, all 22 patients alive are disease free; overall survival and event-free survival (EFS) at 6 years were 70% and 72%, respectively. According to molecular/cytogenetic characteristics, overall survival and EFS for unmutated CLL and/or with 11q- aberration (n = 13) were 90% and 92%, respectively, not significantly different to those with normal in situ hybridization, 13q- and +12, or mutated CLL (n = 7). All six patients with 17p deletion were transplanted with active disease, including three with refractory disease; all except one reached complete remission after the transplant and two are alive and disease free. Nonrelapse mortality (NRM) was 20%; more than two lines before transplant is an independent prognostic factor for NRM (P = 0,02), EFS (P = 0.02), and overall survival (P = 0.01). Patients older than 55 years have a higher risk of NRM (hazard ratio, 12.8; 95% confidence interval, 1.5-111). Minimal residual disease was monitored by multiparametric flow cytometry in 21 patients. Clearance of CD79/CD5/CD19/CD23 cells in bone marrow was achieved in 68% and 94% of the patients at days 100 and 360, respectively. CONCLUSION According to these results, RIC allogeneic transplant could overcome the adverse prognosis of patients with unmutated CLL as well as those with 11q- or 17p-.
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MESH Headings
- Adult
- Aged
- Antigens, CD19/biosynthesis
- CD5 Antigens/biosynthesis
- CD79 Antigens/biosynthesis
- Chromosome Aberrations
- Chromosomes, Human, Pair 11/genetics
- Chromosomes, Human, Pair 17/genetics
- DNA Mutational Analysis
- Disease-Free Survival
- Female
- Flow Cytometry
- Humans
- Immunoglobulin Heavy Chains/chemistry
- Kinetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Mutation
- Prognosis
- Proportional Hazards Models
- Receptors, IgE/biosynthesis
- Risk
- Stem Cells/cytology
- Time Factors
- Transplantation Conditioning/methods
- Transplantation, Homologous/methods
- Treatment Outcome
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Weiss MA, Maslak PG, Jurcic JG, Scheinberg DA, Aliff TB, Lamanna N, Frankel SR, Kossman SE, Horgan D. Pentostatin and cyclophosphamide: an effective new regimen in previously treated patients with chronic lymphocytic leukemia. J Clin Oncol 2003; 21:1278-84. [PMID: 12663715 DOI: 10.1200/jco.2003.08.100] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Purine analogs and alkylators are important agents in the treatment of chronic lymphocytic leukemia (CLL). Previously, combinations of fludarabine and chlorambucil were abandoned because of increased toxicity from overlapping myelosuppression and immunosuppression. Of the purine analogs active in CLL, pentostatin may be least myelosuppressive. We hypothesized that combining pentostatin with cyclophosphamide would have less myelotoxicity than combinations using other purine analogs. PATIENTS AND METHODS We studied 23 patients with previously treated CLL. All patients received pentostatin 4 mg/m(2). Seventeen patients received cyclophosphamide 600 mg/m(2), and six patients received cyclophosphamide 900 mg/m(2). Both drugs were administered on day 1 of each cycle, and cycles were repeated every 3 weeks for six treatments. Filgrastim, sulfamethoxazole/trimethoprim, and acyclovir were administered prophylactically. The median number of prior treatment regimens was three (range, one to five) with 13 patients (57%) refractory to prior fludarabine therapy. RESULTS The cyclophosphamide 900 mg/m(2) dose level was associated with moderate to severe nausea, and we chose cyclophosphamide 600 mg/m(2) as the dose for further study. There were 17 responses (74%; 95% confidence interval, 63% to 85%), including four complete responses. The response rate was 77% in fludarabine-refractory patients. Myelosuppression was acceptable with grade 3/4 neutropenia and thrombocytopenia, seen in 35% and 30% of patients, respectively. The relative sparing of thrombopoiesis can be seen in that only one patient (5%) with an initial platelet count of more than 20,000 required platelet transfusions while receiving therapy. CONCLUSION Pentostatin 4 mg/m(2) with cyclophosphamide 600 mg/m(2) is safe and effective in previously treated patients with CLL. On the basis of these results, we are currently studying pentostatin, cyclophosphamide, and rituximab (PCR) therapy in patients with CLL.
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Affiliation(s)
- Mark A Weiss
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, and Cornell University Medical College, New York, NY 10021, USA.
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5
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Del Poeta G, Maurillo L, Venditti A, Buccisano F, Epiceno AM, Capelli G, Tamburini A, Suppo G, Battaglia A, Del Principe MI, Del Moro B, Masi M, Amadori S. Clinical significance of CD38 expression in chronic lymphocytic leukemia. Blood 2001; 98:2633-9. [PMID: 11675331 DOI: 10.1182/blood.v98.9.2633] [Citation(s) in RCA: 209] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
B-cell chronic lymphocytic leukemia (B-CLL) follows heterogeneous clinical courses, and several biological parameters need to be added to the current clinical staging systems to predict which patients will experience an indolent or an aggressive outcome. This study analyzed CD38 expression by flow cytometry and soluble APO1/Fas (sAPO1/Fas), Bcl-2 (sBcl-2), and CD23 (sCD23) proteins by immunoenzymatic methods to evaluate their effect on the clinical course of 168 unselected B-CLL patients. Intermediate/high risk modified Rai stages were characterized by a higher CD38(+) B-cell number (P =.0002) and higher sCD23 levels (P <.0001). Moreover, CD38(+) B-cell percentages were significantly and directly associated both with beta(2)-microglobulin and sCD23 concentrations (P <.0001 and P =.002, respectively). Both a higher tumor burden (lymphadenopathy/splenomegaly) and a lymphocyte doubling time less than 12 months were significantly associated with higher CD38(+) percentages (P <.0001 and P =.0001, respectively). With regard to clinical outcome, progression-free survival was significantly longer (75% versus 37% at 5 years; P =.00006) in patients with lower CD38(+) B-cell percentages. Furthermore, the risk of partial or no response to fludarabine increased with increasing CD38 expression (P =.003), and a shorter overall survival (50% versus 92% at 8 years; P <.00001) characterized patients with more than 30% CD38(+) B-cell number. The predictive value of CD38 expression was maintained among the patients within the Rai intermediate risk group and was confirmed in multivariate analysis. Thus, the percentage of CD38(+) B cells appears to be an accurate predictor of clinical outcome and therefore could be used to indicate when more novel chemotherapeutic approaches are needed.
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MESH Headings
- ADP-ribosyl Cyclase
- ADP-ribosyl Cyclase 1
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD
- Antigens, Differentiation/metabolism
- B-Lymphocytes/immunology
- B-Lymphocytes/metabolism
- Biomarkers, Tumor/metabolism
- Cohort Studies
- Disease Progression
- Female
- Flow Cytometry
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Membrane Glycoproteins
- Middle Aged
- NAD+ Nucleosidase/metabolism
- Predictive Value of Tests
- Prognosis
- Prospective Studies
- Severity of Illness Index
- Survival Analysis
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Affiliation(s)
- G Del Poeta
- Cattedra e Divisione di Ematologia, Università Tor Vergata, Ospedale S.Eugenio, Roma, Italy.
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