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Pardhi E, Yadav R, Chaurasiya A, Madan J, Guru SK, Singh SB, Mehra NK. Multifunctional targetable liposomal drug delivery system in the management of leukemia: Potential, opportunities, and emerging strategies. Life Sci 2023; 325:121771. [PMID: 37182551 DOI: 10.1016/j.lfs.2023.121771] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/06/2023] [Accepted: 05/07/2023] [Indexed: 05/16/2023]
Abstract
The concern impeding the success of chemotherapy in leukemia treatment is descending efficacy of drugs because of multiple drug resistance (MDR). The previous failure of traditional treatment methods is primarily responsible for the present era of innovative agents to treat leukemia effectively. The treatment option is a chemotherapeutic agent in most available treatment strategies, which unfortunately leads to high unavoidable toxicities. As a result of the recent surge in marketed products, theranostic nanoparticles, i.e., multifunctional targetable liposomes (MFTL), have been approved for improved and more successful leukemia treatment that blends therapeutic and diagnostic characteristics. Since they broadly offer the required characteristics to get past the traditional/previous limitations, such as the absence of site-specific anti-cancer therapeutic delivery and ongoing real-time surveillance of the leukemia target sites while administering therapeutic activities. To prepare MFTL, suitable targeting ligands or tumor-specific antibodies are required to attach to the surface of the liposomes. This review exhaustively covered and summarized the liposomal-based formulation in leukemia treatment, emphasizing leukemia types; regulatory considerations, patents, and clinical portfolios to overcome clinical translation hurdles have all been explored.
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Affiliation(s)
- Ekta Pardhi
- Pharmaceutical Nanotechnology Research Laboratory, Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Hyderabad 500037, Telangana, India
| | - Rati Yadav
- Pharmaceutical Nanotechnology Research Laboratory, Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Hyderabad 500037, Telangana, India
| | - Akash Chaurasiya
- Department of Pharmaceutics, BITS-Pilani, Hyderabad Campus, Jawahar Nagar, Shameerpet Mandal, District. RR, Hyderabad, India
| | - Jitender Madan
- Pharmaceutical Nanotechnology Research Laboratory, Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Hyderabad 500037, Telangana, India
| | - Santosh Kumar Guru
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad 500037, Telangana, India
| | - Shashi Bala Singh
- Department of Biological Sciences, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad 500037, Telangana, India
| | - Neelesh Kumar Mehra
- Pharmaceutical Nanotechnology Research Laboratory, Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research, Hyderabad 500037, Telangana, India.
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Hallek M, Al‐Sawaf O. Chronic lymphocytic leukemia: 2022 update on diagnostic and therapeutic procedures. Am J Hematol 2021; 96:1679-1705. [PMID: 34625994 DOI: 10.1002/ajh.26367] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 12/26/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is one of the most frequent types of leukemia. It typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that interfere with the regulation of proliferation and of apoptosis in clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as typical B-cell markers. PROGNOSIS AND STAGING The clinical staging systems provide prognostic information by using the results of physical examination and blood counts. Various biological and genetic markers provide additional prognostic information. Deletions of the short arm of chromosome 17 (del[17p]) and/or mutations of the TP53 gene predict resistance to chemoimmunotherapy and a shorter time to progression with most targeted therapies. The CLL international prognostic index integrates genetic, biological, and clinical variables to identify distinct risk groups of patients with CLL. THERAPY Only patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. When treatment is indicated, several therapeutic options exist: a combination of the B-cell lymphoma 2 (BCL2) inhibitor venetoclax with obinutuzumab, monotherapy with inhibitors of Bruton tyrosine kinase (BTK) such as ibrutinib and acalabrutinib, or chemoimmunotherapy. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds 3 years. If the disease relapses earlier, therapy should be changed using an alternative regimen. Patients with a del(17p) or TP53 mutation are usually resistant to chemotherapy and should, therefore, be treated with targeted agents. FUTURE CHALLENGES Combinations of targeted agents are now being investigated to create efficient, potentially curative therapies of CLL with fixed duration. One of the most relevant questions currently addressed in clinical trials is the comparison of monotherapies with BTK inhibitors with fixed duration combination therapies. Moreover, the optimal sequencing of targeted therapies remains to be determined. Alternative therapies are needed for patients with BTK and BCL2 inhibitor double-refractory disease.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, Center of Excellence on “Cellular Stress Responses in Aging‐Associated Diseases” University of Cologne Köln Germany
| | - Othman Al‐Sawaf
- Department I of Internal Medicine, University of Cologne, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, Center of Excellence on “Cellular Stress Responses in Aging‐Associated Diseases” University of Cologne Köln Germany
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Abstract
PURPOSE OF REVIEW The treatment landscape of chronic lymphocytic leukaemia (CLL) has tremendously evolved in the last decades, from chemo to chemoimmunotherapy (CIT) and, eventually, to pathway inhibitors that target critical pathways for leukaemic cells survival. Also, treatment goals are moving towards achieving undetectable minimal residual disease with little toxicity. RECENT FINDINGS We performed a thorough review of the history of treatment approvals by both the Food and Drug Administration (FDA) and the European Medicines Agency (EMA). This review especially focuses on therapies that are currently approved by both agencies. The indications and particular characteristics of each drug are examined. SUMMARY Currently available treatment approaches for CLL offer the opportunity to individualize therapy for every single patient with CLL. Inhibitors of B-cell receptor (BCR) signalling pathways and antiapoptotic proteins are nowadays the treatment of choice for most CLL patients, but CIT can be an option for younger and fit patients with low-risk disease [mutated IGHV, no del(11q) or del(17p)/TP53 mutations].
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Steingrímsson V, Lund SH, Dickman PW, Weibull CE, Björkholm M, Landgren O, Kristinsson SY. Survival, causes of death, and the prognostic role of comorbidities in chronic lymphocytic leukemia in the pre-ibrutinib era: A population-based study. Eur J Haematol 2021; 108:145-153. [PMID: 34714556 DOI: 10.1111/ejh.13720] [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: 07/06/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate temporal trends in survival and causes of death in patients with chronic lymphocytic leukemia (CLL) in a nationwide study. METHODS The cohort consisted of 13,009 Swedish CLL patients diagnosed 1982-2013. Relative survival (RS) and excess mortality rate ratios (EMRR) with 95% confidence intervals (95% CIs) were estimated using flexible parametric survival models. Cause-specific hazard ratios (HRs) were estimated for the linear effect of 10-year increase in year of diagnosis. RESULTS The excess mortality decreased comparing 2003-2013 to 1982-1992 (EMRR = 0.53, 95% CI 0.48-0.58). The 5-year RS increased between 1982 and 2012 for patients >51 years at diagnosis and improved for patients ≤51 years after 2002. The rate of CLL-specific deaths decreased over time (HR = 0.78, 95% CI 0.75-0.81). Compared to patients with no comorbidity, patients with 1 and 2+ Charlson Comorbidity Index points had HR = 1.35 (95% CI 1.25-1.45) and HR = 1.47 (95% CI 1.37-1.57) for CLL-related mortality, respectively. CONCLUSION Survival in CLL patients improved in the era of chemoimmunotherapy, and this was largely explained by reduced CLL-related mortality. The increased rate of CLL-related mortality in patients with comorbidities emphasizes the importance of the newer and better tolerated targeted therapy.
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Affiliation(s)
| | - Sigrún H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Paul W Dickman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Caroline E Weibull
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
| | - Magnus Björkholm
- Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ola Landgren
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Sigurður Y Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Smolej L, Vodárek P, Écsiová D, Šimkovič M. Chemoimmunotherapy in the First-Line Treatment of Chronic Lymphocytic Leukaemia: Dead Yet, or Alive and Kicking? Cancers (Basel) 2021; 13:3134. [PMID: 34201565 PMCID: PMC8267736 DOI: 10.3390/cancers13133134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/13/2021] [Accepted: 06/20/2021] [Indexed: 12/23/2022] Open
Abstract
The paradigm of first-line treatment of chronic lymphocytic leukaemia (CLL) is currently undergoing a radical change. On the basis of several randomised phase III trials showing prolongation of progression-free survival, chemoimmunotherapy is being replaced by treatment based on novel, orally available targeted inhibitors such as Bruton tyrosine kinase inhibitors ibrutinib and acalabrutinib or bcl-2 inhibitor venetoclax. However, the use of these agents may be associated with other disadvantages. First, with the exception of one trial in younger/fit patients, no studies have so far demonstrated benefit regarding the ultimate endpoint of overall survival. Second, oral inhibitors are extremely expensive and thus currently unavailable due to the absence of reimbursement in some countries. Third, treatment with ibrutinib and acalabrutinib necessitates long-term administration until progression; this may be associated with accumulation of late side effects, problems with patient compliance, and selection of resistant clones. Therefore, the identification of a subset of patients who could benefit from chemoimmunotherapy would be ideal. Current data suggest that patients with the mutated variable region of the immunoglobulin heavy chain (IGHV) achieve fairly durable remissions, especially when treated with fludarabine, cyclophosphamide, and rituximab (FCR) regimen. This review discusses current options for treatment-naïve patients with CLL.
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Affiliation(s)
- Lukáš Smolej
- 4th Department of Internal Medicine–Hematology, Faculty of Medicine, University Hospital, Charles University, 50005 Hradec Králové, Czech Republic; (P.V.); (D.É.); (M.Š.)
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Steingrímsson V, Gíslason GK, Aspelund T, Turesson I, Björkholm M, Landgren O, Kristinsson SY. A population-based study on serious inpatient bacterial infections in patients with chronic lymphocytic leukemia and their impact on survival. Eur J Haematol 2020; 105:547-554. [PMID: 32575150 DOI: 10.1111/ejh.13477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Infections in chronic lymphocytic leukemia (CLL) have been thoroughly investigated in the setting of clinical trials and single-center studies. However, large cohort studies on real-world data and studies on temporal trends are lacking. We performed a nationwide study on serious bacterial infections in CLL. METHODS Using high-quality Swedish government-based registries, 13 009 CLL patients diagnosed in 1982-2013 and their 49 380 matched controls were included. RESULTS Overall, CLL patients had an increased risk of serious inpatient bacterial infections with a hazard ratio (HR) 5.32 and 95% confidence interval (95% CI) 5.11-5.53, and the highest risk was observed for septicemia (HR 6.91, 95% CI 6.46-7.39) and lung infections (5.91, 5.64-6.18). The risk of serious inpatient bacterial infections decreased overtime with HR 0.87 (0.81-0.94) and HR 0.76 (0.70-0.82) in 1993-2002 and 2003-2013, respectively, compared to 1982-1992. CLL patients had an increased risk of death following a serious inpatient bacterial infection compared to matched CLL patients, and the risk was highest in the first 12 months after the infection (HR 5.48, 95% CI 5.11-5.90). CONCLUSION We have, in this nationwide study, characterized the risk of serious bacterial infections in CLL patients and, importantly, depicted that the risk has decreased overtime.
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Affiliation(s)
| | | | - Thor Aspelund
- Centre for Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Ingemar Turesson
- Department of Hematology and Coagulation Disorders, Skane University Hospital, Malmö, Sweden
| | - Magnus Björkholm
- Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ola Landgren
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sigurdur Y Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Hallek M. Chronic lymphocytic leukemia: 2020 update on diagnosis, risk stratification and treatment. Am J Hematol 2019; 94:1266-1287. [PMID: 31364186 DOI: 10.1002/ajh.25595] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen, as well as typical B-cell markers. PROGNOSIS The two similar clinical staging systems, Rai and Binet, create prognostic information by using results of physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del [17p]) and/or mutations of the TP53 gene, predict resistance to chemoimmunotherapy and a shorter time to progression, with most targeted therapies. A comprehensive, international prognostic score (CLL-IPI) integrates genetic, biological and clinical variables to identify distinct risk groups of CLL patients. THERAPY Only patients with active or symptomatic disease, or with advanced Binet or Rai stages require therapy. When treatment is indicated, several options exist for most CLL patients: a combination of venetoclax with obinutuzumab, ibrutinib monotherapy, or chemoimmunotherapy. For physically fit patients younger than 65 (in particular when presenting with a mutated IGVH gene), chemoimmunotherapy with fludarabine, cyclophosphamide and rituximab remains a standard therapy, since it may have curative potential. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds 3 years. If the disease relapses earlier, therapy should be changed using an alternative regimen. Patients with a del (17p) or TP53 mutation are a different, high-risk category and should be treated with targeted agents. An allogeneic SCT may be considered in relapsing patients with TP53 mutations or del (17p), or patients that are refractory to inhibitor therapy. FUTURE CHALLENGES Targeted agents (ibrutinib, idelalisib, venetoclax, obinutuzumab) will be increasingly used in combination to allow for short, but potentially definitive therapies of CLL. It remains to be proven that they generate a superior outcome when compared to monotherapies with inhibitors of Bruton tyrosine kinase, which can also yield long-lasting remissions. Moreover, the optimal sequencing of drug combinations is unknown. Therefore, CLL patients should be treated in clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal MedicineUniversity of Cologne, Center for Integrated Oncology Aachen Bonn Köln Düsseldorf, Center of Excellence on “Cellular Stress Responses in Aging‐Associated Diseases” Köln Germany
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Rateau Y, Harbouche M, Damaj G, Troussard X. [Evaluation of management disparity in patients with chronic lymphocytic leukemia in France]. Bull Cancer 2018; 105:1147-1156. [PMID: 30396506 DOI: 10.1016/j.bulcan.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/15/2018] [Accepted: 08/27/2018] [Indexed: 11/20/2022]
Abstract
Environmental factors have an impact on the effectiveness of treatments for chronic lymphocytic leukemia: vulnerability, organization of the supply of care and proximity of the patient to health professionals. The disparity of care was assessed; vulnerability by the European index of deprivation, the provision of care by values of localized potential accessibility to general practitioners, nurses and pharmacists and hospital supply by the density of hematologists and time access to the center. The data, extracted from the public databases for each grouped island for statistical information, were cross-referenced to apply a principal component analysis and group them into 4 clusters. Cluster 1 has an average EDI, easy access to city professionals, remote access to the referral center, and a good density of hematologists. Cluster 2 has low EDI, satisfactory access to professionals, satisfactory proximity to the referral center and average density of hematologists. Cluster 3 has good EDI, access to professionals is difficult, access to the reference center is long, and the density of hematologists remains average. Cluster 4 has a good EDI, with access to professionals easier than in Cluster 3 but still difficult. The access time to the reference center is better than that of cluster 3 but remains elongated, the density of hematologists remaining average. Mapping is a tool for hospitals and institutions to evaluate care and compare it to other territories.
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Affiliation(s)
- Yann Rateau
- YUNI, 20, rue des Volontaires, 75015 Paris, France
| | | | - Gandhi Damaj
- CHU de Caen, service hématologie clinique, IHBN, 14000 Caen, France
| | - Xavier Troussard
- CHU de Caen, laboratoire d'hématologie, avenue de la Côte-de-Nacre, 14000 Caen, France.
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Kantarjian HM, Keating MJ, Freireich EJ. Toward the potential cure of leukemias in the next decade. Cancer 2018; 124:4301-4313. [DOI: 10.1002/cncr.31669] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/22/2018] [Accepted: 06/04/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Hagop M. Kantarjian
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Michael J. Keating
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Emil J Freireich
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
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Chronic lymphocytic leukemia and infection risk in the era of targeted therapies: Linking mechanisms with infections. Blood Rev 2018; 32:387-399. [DOI: 10.1016/j.blre.2018.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 03/09/2018] [Accepted: 03/15/2018] [Indexed: 01/07/2023]
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Byrd JC, Ruppert AS, Heerema NA, Halvorson AE, Hoke E, Smith MR, Godwin JE, Couban S, Fehniger TA, Thirman MJ, Tallman MS, Appelbaum FR, Stone RM, Robinson S, Chang JE, Mandrekar SJ, Larson RA. Lenalidomide consolidation benefits patients with CLL receiving chemoimmunotherapy: results for CALGB 10404 (Alliance). Blood Adv 2018; 2:1705-1718. [PMID: 30030269 PMCID: PMC6058242 DOI: 10.1182/bloodadvances.2017015396] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/28/2018] [Indexed: 02/07/2023] Open
Abstract
Prior to novel targeted agents for chronic lymphocytic leukemia (CLL), the best chemoimmunotherapy regimen in patients with non-del(11q) disease was unclear. The role of lenalidomide was also not defined. This phase 2 study randomized 342 untreated patients with non-del(11q) CLL requiring therapy to fludarabine plus rituximab (FR; n = 123), FR plus lenalidomide consolidation (FR+L; n = 109), or FR plus cyclophosphamide (FCR; n = 110) and compared 2-year progression-free survival (PFS) rates of each to the historical control rate with FC (60%). Patients with del(11q) in at least 20% of pretreatment cells continued with FCR (n = 27) or were reassigned to FCR+L (n = 31) and excluded from the primary analysis. Among non-del(11q) patients, 2-year PFS rates were 64% (90% confidence interval [CI], 57-71; FR), 72% (90% CI, 65-79; FR+L), and 74% (90% CI, 66-80; FCR); FR+L and FCR had rates significantly greater than historical control. Median PFS was significantly shorter with FR compared with FR+L (P = .04) and FCR (P < .001): 43 (95% CI, 33-50), 61 (95% CI, 45-71), and 97 (95% CI, 61 to not reached) months, respectively. Median follow-up was 73 months and median overall survival (OS) was only reached with FCR (101 months; 95% CI, 96 to not reached). With FR+L, the risk of death decreased over time and was lower than with FR at later time points (P = .01), but not significantly different from FCR (P = .21). Future studies incorporating short courses of lenalidomide into other novel treatment regimens are justified.
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Affiliation(s)
| | - Amy S Ruppert
- Division of Hematology
- Alliance Statistics and Data Center, and
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | | | - Eva Hoke
- Alliance Statistics and Data Center, Duke University, Durham, NC
| | - Mitchell R Smith
- Department of Medical Oncology and Hematology, George Washington University Cancer Center, Washington, DC
| | | | | | - Todd A Fehniger
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Michael J Thirman
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | | | - Richard M Stone
- Dana-Farber/Partners CancerCare, Harvard Cancer Center, Boston, MA; and
| | - Sue Robinson
- QEII Health Sciences Centre, Halifax, NS, Canada
| | - Julie E Chang
- Department of Medicine, University of Wisconsin, Madison, WI
| | | | - Richard A Larson
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
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Robak T, Błoński J, Skotnicki AB, Piotrowska M, Wróbel T, Rybka J, Kłoczko J, Bołkun Ł, Budziszewska BK, Walczak U, Uss A, Fidecka M, Smolewski P. Rituximab, cladribine, and cyclophosphamide (RCC) induction with rituximab maintenance in chronic lymphocytic leukemia: PALG - CLL4 (ML21283) trial. Eur J Haematol 2018; 100:465-474. [PMID: 29427355 DOI: 10.1111/ejh.13042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES PALG CLL4 is the first, randomized, phase IIIb study with rituximab, cladribine, and cyclophosphamide (RCC) induction and subsequent maintenance with rituximab in previously untreated chronic lymphocytic leukemia (CLL) patients. METHODS The induction treatment consisted of 6 RCC cycles regimen. Patients with complete response (CR) or partial response (PR) after an induction phase were randomized into a maintenance arm with rituximab or an observational arm. RESULTS In the intention-to-treat population, 97 patients completed the induction phase with an overall response rate (ORR) of 73.2% (CR 22.7%, PR 50.5%). Subsequently, 66 patients were randomized into the rituximab maintenance arm (n = 33) or the observational arm (n = 33). CR rates were 57.1% in the maintenance group vs 50% in the observational group. PFS was significantly longer in the rituximab maintenance vs the observational arm (P = .028). The multivariate Cox model indicated that del17p (P = .006) and elevated beta-2-microglobulin (P = .015) significantly increased the hazard ratio (HR) of progression, whereas the presence of CD38 (P = .013) significantly decreased it; maintenance therapy with rituximab (P < .0001) significantly decreased the HR of disease progression. CONCLUSIONS The study confirmed the high efficacy and acceptable safety profile of induction therapy with RCC and maintenance therapy with rituximab in previously untreated patients with CLL.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | - Jerzy Błoński
- Department of Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
| | | | | | - Tomasz Wróbel
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Justyna Rybka
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wroclaw, Poland
| | - Janusz Kłoczko
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | - Łukasz Bołkun
- Department of Hematology, Medical University of Białystok, Białystok, Poland
| | | | - Urszula Walczak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Anatoly Uss
- City Clinical Hospital No. 9, Minsk, Belarus
| | | | - Piotr Smolewski
- Department of Experimental Hematology, Copernicus Memorial Hospital, Medical University of Lodz, Lodz, Poland
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Caimi PF, Cooper BW, William BM, Dowlati A, Barr PM, Fu P, Pink J, Xu Y, Lazarus HM, de Lima M, Gerson SL. Phase I clinical trial of the base excision repair inhibitor methoxyamine in combination with fludarabine for patients with advanced hematologic malignancies. Oncotarget 2017; 8:79864-79875. [PMID: 29108368 PMCID: PMC5668101 DOI: 10.18632/oncotarget.20094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/26/2017] [Indexed: 02/07/2023] Open
Abstract
PURPOSE We determined the safety, pharmacokinetics, pharmacodynamics and recommended phase II dose of the base excision repair blocker methoxyamine combined with fludarabine. MATERIALS AND METHODS This was a phase I study with intravenous fludarabine (25 mg/m2, days 1-5), and methoxyamine (15 mg/m2-120 mg/m2, once). A maximum of six cycles were given. Adult patients with relapsed/refractory hematologic malignancies, excluding acute myeloid leukemia, were eligible. RESULTS Twenty patients were treated; diagnoses included CLL/SLL (n = 10), follicular lymphoma (n = 3), DLBCL (n = 3), mantle cell lymphoma (n = 1), anaplastic large cell lymphoma (n = 1) and plasma cell myeloma (n = 2). No DLTs were observed and dose escalation reached the maximum planned dose. Hematologic toxicity was frequent; most common grade 3-4 toxicities were lymphopenia (70%), neutropenia (60%), leukopenia (50%) and anemia (40%). Four patients achieved a partial remission and 8 achieved stable disease. The drug combination resulted in increased DNA damage measured with the Comet assay. CONCLUSIONS Methoxyamine combined with fludarabine was safe and well tolerated. Hematologic toxicity was comparable to single agent fludarabine. Activity appears to correlate with increased levels of DNA damage. Further studies will examine use of this combination of as part conditioning regimens of stem cell transplant and use of methoxyamine as fludarabine dose-sparing agent.
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Affiliation(s)
- Paolo F. Caimi
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Brenda W. Cooper
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Basem M. William
- Division of Hematology. The Ohio State University Medical School, Columbus, Ohio, USA
| | - Afshin Dowlati
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Paul M. Barr
- Division of Hematology and Oncology, Department of Medicine, University of Rochester, Rochester, New York, USA
| | - Pingfu Fu
- Department of Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA
| | - John Pink
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Yan Xu
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Hillard M. Lazarus
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Marcos de Lima
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
| | - Stanton L. Gerson
- Case Comprehensive Cancer Center, Cleveland, Ohio, USA
- Division of Hematology and Oncology, Department of Medicine, University Hospitals Seidman Cancer Center, Cleveland, Ohio, USA
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14
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Hallek M. Chronic lymphocytic leukemia: 2017 update on diagnosis, risk stratification, and treatment. Am J Hematol 2017; 92:946-965. [PMID: 28782884 DOI: 10.1002/ajh.24826] [Citation(s) in RCA: 190] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 12/12/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen and B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) and/or mutations of the TP53 gene predict resistance to available chemotherapies. A comprehensive prognostic score (CLL-IPI) using genetic, biological, and clinical variables has recently been developed allowing to classify CLL into very distinct risk groups. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physically fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab remains the current standard therapy. For unfit patients, currently available evidence supports two options for a first-line therapy: chlorambucil combined with an anti-CD20 antibody (obinutuzumab or rituximab or ofatumumab) or a continuous therapy with ibrutinib. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds 3 years. If the disease relapses earlier, therapy should be changed using alternative agents such as bendamustine (plus rituximab), alemtuzumab, lenalidomide, ofatumumab, ibrutinib, idelalisib, or venetoclax. Patients with a del(17p) or TP53 mutation can be treated with ibrutinib, venetoclax, or a combination of idelalisib and rituximab. An allogeneic SCT may be considered in relapsing patients with TP53 mutations or del(17p) or patients that are refractory to chemoimmunotherapy and the novel inhibitors. FUTURE CHALLENGES The new agents (ibrutinib, idelalisib, venetoclax, and obinutuzumab) hold the potential to significantly improve the outcome of CLL patients. However, their optimal use (in terms of combination, sequence, and duration) remains unknown. Therefore, CLL patients should be treated in clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Kerpener Strasse 62 Köln 50937 Germany
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15
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Early, risk-adapted treatment with fludarabine in Binet stage A chronic lymphocytic leukemia patients: results of the CLL1 trial of the German CLL study group. Leukemia 2017; 31:2833-2837. [DOI: 10.1038/leu.2017.246] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Salem A, Loghavi S, Khoury JD, Agbay RLMC, Jorgensen JL, Medeiros LJ. Herpes simplex infection simulating Richter transformation: a series of four cases and review of the literature. Histopathology 2016; 70:821-831. [PMID: 27905140 DOI: 10.1111/his.13137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/26/2016] [Indexed: 12/27/2022]
Abstract
AIMS Richter transformation (RT) occurs in 5-10% of patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL), and is associated with a poor outcome. The histological manifestations of RT are variable, and include an increase in the proportion of prolymphocytes, immunoblasts, and other pleomorphic cells, along with an increased proliferation rate and often necrosis. Rarely, superimposed herpes simplex virus (HSV) infection involving lymph nodes in patients with CLL/SLL may mimic RT clinically and histologically. In this study, we describe four cases of CLL/SLL with superimposed HSV lymphadenitis, and we review the literature. METHODS AND RESULTS We describe the clinicopathological and immunophenotypic findings of four cases of CLL/SLL with superimposed HSV infection. The patients presented with B-type symptoms, and laboratory and imaging findings suggested progression of lymphoma. Histologically, there were geographical areas of necrosis and increased numbers of prolymphocytes and immunoblasts, in some areas forming sheets, with increased mitotic figures and a high proliferation (Ki67) rate. However, the necrotic regions were associated with acute inflammatory cells and larger cells, mostly necrotic, showing viral cytopathic effects. Therapy with antiviral agents resulted in improvement of clinical symptoms and laboratory and imaging findings. Additionally, we identified 11 cases of CLL/SLL with superimposed HSV infection described in the English-language literature, and integrated the cases that we report here into this wider context. CONCLUSIONS Herpes simplex virus infection of lymph nodes in patients with CLL/SLL results in clinicopathological and radiological findings that may mimic RT. It is essential to refrain from misclassifying these cases as RT, as patients can respond remarkably well to antiviral therapy.
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Affiliation(s)
- Alireza Salem
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Rose Lou Marie C Agbay
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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17
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Flinn IW, Ruppert AS, Harwin W, Waterhouse D, Papish S, Jones JA, Hainsworth J, Byrd JC. A phase II study of two dose levels of ofatumumab induction followed by maintenance therapy in symptomatic, previously untreated chronic lymphocytic leukemia. Am J Hematol 2016; 91:1020-5. [PMID: 27387131 DOI: 10.1002/ajh.24468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/03/2016] [Accepted: 07/05/2016] [Indexed: 12/22/2022]
Abstract
Despite the recent advances in treatment of CLL with targeted agents such as ibrutinib, availability of nonchemotherapy based therapies is desired. Given the 58% response rate (1996 NCI-WG criteria) of single agent ofatumumab in CLL refractory to fludarabine and alemtuzumab, we initiated a phase II trial examining response, safety, and progression-free survival (PFS) of ofatumumab as front-line monotherapy. Patients enrolled included untreated, symptomatic CLL patients over the age of 65 or those who were inappropriate/did not desire chemotherapy. Two cohorts were enrolled sequentially examining either 1 g (33 patients) or 2 g (44 patients) weekly for 8 weeks followed by maintenance dosing every 2 months for a total of 24 months. Patients receiving 1 g were older than those receiving 2 g, but there were no significant differences in other clinical characteristics. The best overall response rates in the 1 and 2 g patient cohorts were 72 and 89% (1996 NCI-WG criteria), respectively (54 and 68%, respectively, using 2008 IWCLL criteria). All but two responses were partial. The 24-month estimated PFS rates were 46 and 78%, respectively. Response and PFS was lower in del(17p) and del(11q) CLL patients. Differences in PFS between dose cohorts were statistically significant and remained so when adjusting for age or high-risk cytogenetics. Toxicity of this treatment was mild with only six patients not completing therapy due to toxicity. Ofatumumab induction followed by maintenance therapy in untreated CLL represents a well-tolerated and active regimen, particularly with the 2 g of ofatumumab. Am. J. Hematol. 91:1020-1025, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ian W. Flinn
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - Amy S. Ruppert
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - William Harwin
- Sarah Cannon Research Institute; Nashville Tennessee
- Florida Cancer Specialists; Ft. Myers Florida
| | - David Waterhouse
- Sarah Cannon Research Institute; Nashville Tennessee
- Oncology Hematology Care; Cincinnati Ohio
| | - Steven Papish
- Hematology-Oncology Associates of Northern NJ; Morristown New Jersey
| | - Jeffrey A. Jones
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
| | - John Hainsworth
- Sarah Cannon Research Institute; Nashville Tennessee
- Tennessee Oncology; Nashville Tennessee
| | - John C. Byrd
- Division of Hematology and Comprehensive Cancer Center at the Ohio State University; Columbus Ohio
- Division of Medicinal Chemistry; College of Pharmacy, The Ohio State University; Columbus Ohio
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18
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Rodrigues CA, Gonçalves MV, Ikoma MRV, Lorand-Metze I, Pereira AD, Farias DLCD, Chauffaille MDLLF, Schaffel R, Ribeiro EFO, Rocha TSD, Buccheri V, Vasconcelos Y, Figueiredo VLDP, Chiattone CS, Yamamoto M. Diagnosis and treatment of chronic lymphocytic leukemia: recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia. Rev Bras Hematol Hemoter 2016; 38:346-357. [PMID: 27863764 PMCID: PMC5119662 DOI: 10.1016/j.bjhh.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 02/06/2023] Open
Abstract
Chronic lymphocytic leukemia is characterized by clonal proliferation and progressive accumulation of B-cell lymphocytes that typically express CD19+, CD5+ and CD23+. The lymphocytes usually infiltrate the bone marrow, peripheral blood, lymph nodes, and spleen. The diagnosis is established by immunophenotyping circulating B-lymphocytes, and prognosis is defined by two staging systems (Rai and Binet) established by physical examination and blood counts, as well as by several biological and genetic markers. In this update, we present the recommendations from the Brazilian Group of Chronic Lymphocytic Leukemia for the diagnosis and treatment of chronic lymphocytic leukemia. The following recommendations are based on an extensive literature review with the aim of contributing to more uniform patient care in Brazil and possibly in other countries with a similar social–economic profile.
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Affiliation(s)
- Celso Arrais Rodrigues
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Hospital Sírio Libanês, São Paulo, SP, Brazil.
| | - Matheus Vescovi Gonçalves
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil; Fleury Medicina e Saúde, São Paulo, SP, Brazil
| | | | | | | | | | | | - Rony Schaffel
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | | | - Talita Silveira da Rocha
- A.C Camargo Cancer Center, São Paulo, SP, Brazil; Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | - Valeria Buccheri
- Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, SP, Brazil
| | - Yuri Vasconcelos
- Instituto Goiano de Oncologia e Hematologia (INGOH), Goiânia, GO, Brazil
| | | | - Carlos Sérgio Chiattone
- Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil; Hospital Samaritano, São Paulo, SP, Brazil
| | - Mihoko Yamamoto
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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19
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Rigoni M, Riganti C, Vitale C, Griggio V, Campia I, Robino M, Foglietta M, Castella B, Sciancalepore P, Buondonno I, Drandi D, Ladetto M, Boccadoro M, Massaia M, Coscia M. Simvastatin and downstream inhibitors circumvent constitutive and stromal cell-induced resistance to doxorubicin in IGHV unmutated CLL cells. Oncotarget 2016; 6:29833-46. [PMID: 26284584 PMCID: PMC4745766 DOI: 10.18632/oncotarget.4006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 05/15/2015] [Indexed: 01/31/2023] Open
Abstract
The immunoglobulin heavy-chain variable region (IGHV) mutational status is a strong determinant of remission duration in chronic lymphocytic leukemia (CLL). The aim of this work was to compare the multidrug resistance (MDR) signature of IGHV mutated and unmutated CLL cells, identifying biochemical and molecular targets potentially amenable to therapeutic intervention. We found that the mevalonate pathway-dependent Ras/ERK1–2 and RhoA/RhoA kinase signaling cascades, and the downstream HIF-1α/P-glycoprotein axis were more active in IGHV unmutated than in mutated cells, leading to a constitutive protection from doxorubicin-induced cytotoxicity. The constitutive MDR phenotype of IGHV unmutated cells was partially dependent on B cell receptor signaling, as shown by the inhibitory effect exerted by ibrutinib. Stromal cells further protected IGHV unmutated cells from doxorubicin by upregulating Ras/ERK1–2, RhoA/RhoA kinase, Akt, HIF-1α and P-glycoprotein activities. Mevalonate pathway inhibition with simvastatin abrogated these signaling pathways and reversed the resistance of IGHV unmutated cells to doxorubicin, also counteracting the protective effect exerted by stromal cells. Similar results were obtained via the targeted inhibition of the downstream molecules ERK1–2, RhoA kinase and HIF-1α. Therefore, targeting the mevalonate pathway and its downstream signaling cascades is a promising strategy to circumvent the MDR signature of IGHV unmutated CLL cells.
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Affiliation(s)
- Micol Rigoni
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Riganti
- Department of Oncology, University of Torino, Torino, Italy
| | - Candida Vitale
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Valentina Griggio
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Ivana Campia
- Department of Oncology, University of Torino, Torino, Italy
| | - Marta Robino
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Myriam Foglietta
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Barbara Castella
- Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Patrizia Sciancalepore
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Daniela Drandi
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Marco Ladetto
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Mario Boccadoro
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Massimo Massaia
- Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy.,S.C. Ematologia e Terapie Cellulari, Azienda Ospedaliera Ordine Mauriziano di Torino, Torino, Italy
| | - Marta Coscia
- Division of Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy.,Center for Experimental Research and Medical Studies, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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20
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Randhawa JK, Ferrajoli A. A review of supportive care and recommended preventive approaches for patients with chronic lymphocytic leukemia. Expert Rev Hematol 2016; 9:235-44. [PMID: 26652692 DOI: 10.1586/17474086.2016.1129893] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent type of adult leukemia encountered in the western world. Patients with CLL are typically older, with a median age in the 70s, and are at risk for certain complications due to the disease itself and due to the therapies imparted for this. Patients with CLL are at a higher risk of infections, partly due to disease and partly due to the immune dysfunction induced by treatment, such as purine analogous-based chemoimmunotherapy, which leads to lymphocyte depletion. Infections are a leading cause of complications and death in CLL patients. Also, CLL patients have been shown to have a higher incidence of other malignancies. Despite this knowledge, there are no definite guidelines as to what is the best approach to manage or prevent these associated complications of CLL. In this review, the authors discuss the data available and outline recommendations as to the best way to approach this issue in daily practice.
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Affiliation(s)
- Jasleen K Randhawa
- a Department of Leukemia , University of Texas M. D. Anderson Cancer Center , Houston , TX , USA
| | - Alessandra Ferrajoli
- a Department of Leukemia , University of Texas M. D. Anderson Cancer Center , Houston , TX , USA
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21
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Langerbeins P, Groß-Ophoff-Müller C, Herling CD. Risk-Adapted Therapy in Early-Stage Chronic Lymphocytic Leukemia. Oncol Res Treat 2016; 39:18-24. [DOI: 10.1159/000443013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022]
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22
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Outcomes for patients with chronic lymphocytic leukemia and acute leukemia or myelodysplastic syndrome. Leukemia 2015; 30:325-30. [PMID: 26290497 DOI: 10.1038/leu.2015.227] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/19/2015] [Accepted: 07/22/2015] [Indexed: 12/31/2022]
Abstract
Acute leukemia (AL) and myelodysplastic syndrome (MDS) are uncommon in chronic lymphocytic leukemia (CLL). We retrospectively identified 95 patients with CLL, also diagnosed with AL (n=38) or MDS (n=57), either concurrently (n=5) or subsequent (n=90) to CLL diagnosis and report their outcomes. Median number of CLL treatments prior to AL and MDS was 2 (0-9) and 1 (0-8), respectively; the most common regimen was purine analog combined with alkylating agent±CD20 monoclonal antibody. Twelve cases had no prior CLL treatment. Among 38 cases with AL, 33 had acute myelogenous leukemia (AML), 3 had acute lymphoid leukemia (ALL; 1 Philadelphia chromosome positive), 1 had biphenotypic and 1 had extramedullary (bladder) AML. Unfavorable AML karyotype was noted in 26, and intermediate risk in 7 patients. There was no association between survival from AL and number of prior CLL regimens or karyotype. Expression of CD7 on blasts was associated with shorter survival. Among MDS cases, all International Prognostic Scoring System (IPSS) were represented; karyotype was unfavorable in 36, intermediate in 6 and favorable in 12 patients; 10 experienced transformation to AML. Shorter survival from MDS correlated with higher risk IPSS, poor-risk karyotype and increased number of prior CLL treatments. Overall, outcomes for patients with CLL subsequently diagnosed with AL or MDS were very poor; AL/MDS occurred without prior CLL treatment. Effective therapies for these patients are desperately needed.
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23
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Morrison VA. Immunosuppression associated with novel chemotherapy agents and monoclonal antibodies. Clin Infect Dis 2015; 59 Suppl 5:S360-4. [PMID: 25352632 DOI: 10.1093/cid/ciu592] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The introduction of novel agents to the therapeutic armamentarium for oncologic, rheumatologic, and neurologic disorders has resulted in major clinical advances. These agents impact immune function, resulting in a discrete spectrum of infectious complications. Purine analogues and alemtuzumab alter cell-mediated immunity, resulting in opportunistic viral/fungal infections. Herpes zoster incidence increases with bortezomib. Hepatitis B reactivation may occur with rituximab. Cases of progressive multifocal leukoencephalopathy have occurred following monoclonal antibody therapy. Tumor necrosis factor-α inhibitor therapy is complicated by tuberculosis reactivation and fungal infections. We summarize the impact of these therapies on pathogenesis and spectrum of infection complicating their usage.
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Affiliation(s)
- Vicki A Morrison
- Hematology, Oncology and Infectious Diseases, University of Minnesota/Minneapolis VAMC
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24
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The rate of in vitro fludarabine-induced peripheral blood and bone marrow cell apoptosis may predict the chemotherapy outcome in patients with chronic lymphocytic leukemia. Eur J Clin Pharmacol 2015; 71:1121-7. [PMID: 26141594 PMCID: PMC4532719 DOI: 10.1007/s00228-015-1893-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 06/23/2015] [Indexed: 12/25/2022]
Abstract
Purpose The problem of drug sensitivity and predicting the outcome of chemotherapy seems to be of great importance in hemato-oncological disorders. There are some factors that can help to predict effects of chemotherapy in chronic lymphocytic leukemia (CLL), such as presence of del17p, del11q, or TP53 gene mutations, which result in resistance to purine analogues and alkylating drugs. Despite the new therapeutic options introduced recently, purine analogues in combination with cyclophosphamide and the monoclonal antibody rituximab is still the gold standard for the first-line treatment of fit patients with CLL. The aim of this study was to assess whether the rate of apoptosis caused by one of purine analogues—fludarabine in cell cultures differs between patients who clinically respond to fludarabine-based chemotherapy and those who do not respond. Methods CLL leukemic cells, obtained from peripheral blood and bone marrow of 23 patients, were cultured in the presence of fludarabine. After 24 h of incubation, the rate of apoptosis, indicated by the expression of active caspase-3, was assessed with flow cytometry and then analyzed regarding clinical response to fludarabine-based regimens. Results The percentage of apoptotic cells induced by fludarabine was significantly higher in the group of patients who achieved remission in comparison to the group with no response to purine analogues therapy. Interestingly, we observed that among the patients who did not respond to chemotherapy, the presence of del17p and del11q was detected only once. Other non-responders had no detectable genetic abnormalities. Conclusions Based on these results, it can be presumed that in vitro drug sensitivity test, which is easy to perform, may predict the outcome of fludarabine-based chemotherapy in CLL patients. Electronic supplementary material The online version of this article (doi:10.1007/s00228-015-1893-0) contains supplementary material, which is available to authorized users.
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25
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Beauchemin C, Johnston JB, Lapierre MÈ, Aissa F, Lachaine J. Relationship between progression-free survival and overall survival in chronic lymphocytic leukemia: a literature-based analysis. ACTA ACUST UNITED AC 2015; 22:e148-56. [PMID: 26089725 DOI: 10.3747/co.22.2119] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The endpoints of progression-free survival (pfs) and time-to-progression (ttp) are frequently used to evaluate the clinical benefit of anticancer drugs. However, the surrogacy of those endpoints for overall survival (os) is not validated in all cancer settings. In the present study, we used a trial-based approach to assess the relationship between median pfs or ttp and median os in chronic lymphocytic leukemia (cll). METHODS The pico (population, interventions, comparators, outcomes) method was used to conduct a systematic review of the literature. The population consisted of patients with cll; the interventions and comparators were standard therapies for cll; and the outcomes were median pfs, ttp, and os. Two independent reviewers screened titles, abstracts, and full papers for eligibility and then extracted data from selected studies. Correlation coefficients were calculated to assess the relationship between median pfs or ttp and median os. Subgroup correlation analyses were also conducted according to the characteristics of the selected studies (such as line of treatment and type of treatment under investigation). RESULTS Of the 1263 potentially relevant articles identified during the literature search, twenty-three were included. On average, median pfs or ttp was 16.0 months (standard deviation: 12.4 months) and median os was 43.5 months (standard deviation: 31.2 months). Results of the correlation analysis indicated that median pfs or ttp is highly correlated with median os (Spearman correlation coefficient: 0.813; p ≤ 0.001). A significant correlation between median pfs or ttp and median os was observed in second- and subsequent-line therapies, but not in the first-line setting. CONCLUSIONS Our study demonstrates a strong correlation between median pfs or ttp and median os in previously treated cll, which reinforce the hypothesis that pfs and ttp could be adequate surrogate endpoints for os in this cancer setting.
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Affiliation(s)
| | - J B Johnston
- Manitoba Institute of Cell Biology, Winnipeg, MB
| | | | - F Aissa
- Lundbeck Canada, Montreal, QC
| | - J Lachaine
- Faculty of Pharmacy, University of Montreal, QC
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26
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Owen C, Bence-Bruckler I, Chamakhi I, Toze C, Assaily W, Christofides A, Robinson S. A canadian perspective on the first-line treatment of chronic lymphocytic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:303-13. [PMID: 25937158 DOI: 10.1016/j.clml.2015.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 12/11/2022]
Abstract
Despite important advances in the treatment of first-line chronic lymphocytic leukemia (CLL) over the past decade, CLL remains an incurable disease with significant unmet needs. The combination of rituximab with fludarabine and cyclophosphamide (FCR) significantly improved overall survival and progression-free survival compared with fludarabine and cyclophosphamide alone in first-line treatment of CLL. However, because of its high toxicity, FCR is only recommended for younger, fit patients who can tolerate the treatment. This excludes a large fraction of CLL patients who are elderly and/or who have comorbidities. Thus, determining the appropriate treatment choices for this group of patients who are unfit for FCR treatment is a significant challenge in CLL. Current treatment choices in Canadian practice include bendamustine with rituximab, fludarabine with rituximab, and chlorambucil with rituximab. Two novel monoclonal antibodies, ofatumumab and obinutuzumab, have also recently received Health Canada approval for the first-line treatment of CLL patients in combination with chlorambucil. In addition, the Bruton tyrosine kinase inhibitor, ibrutinib, has recently been approved by Health Canada for the first-line treatment of CLL patients with deletion 17p. In the coming years, several other novel agents that are being developed are likely to change the CLL treatment landscape dramatically, however, because these novel agents are currently unavailable, the purpose of this review is to recommend the best treatment approaches in Canada using currently available therapies.
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Affiliation(s)
- Carolyn Owen
- Foothills Medical Centre & Tom Baker Cancer Centre, Calgary, Alberta, Canada.
| | | | - Inès Chamakhi
- Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Cynthia Toze
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | - Sue Robinson
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Hallek M. Chronic lymphocytic leukemia: 2015 Update on diagnosis, risk stratification, and treatment. Am J Hematol 2015; 90:446-60. [PMID: 25908509 DOI: 10.1002/ajh.23979] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) predict resistance to available chemotherapies. Comprehensive prognostic scores are currently being developed. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physical fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab remains the current standard therapy. For unfit patients, treatment with an anti-CD20 antibody (obinutuzumab or rituximab or ofatumumab) plus a milder chemotherapy (Chlorambucil) may be applied. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds two to three years. If the disease relapses earlier, therapy should be changed using alternative agents such as bendamustine (plus rituximab), alemtuzumab, lenalidomide, ofatumumab, ibrutinib, or idelalisib. Patients with a del(17p) or TP53 mutation can be treated with ibrutinib or a combination of idelalisib and rituximab. An allogeneic SCT may be considered in relapsing patients with TP53 mutations or del(17p) or patients that are refractory to repeated chemoimmunotherapies. Future challenges: Several new agents (e.g., ibrutinib, idelalisib, obinutuzumab) hold the potential to improve the outcome of patients with CLL. However, their optimal use (in terms of combination, sequence, and duration) is unknown. Therefore, CLL patients should be treated in clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases”, University of Cologne; Cologne Germany
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Lucas DM, Ruppert AS, Lozanski G, Dewald GW, Lozanski A, Claus R, Plass C, Flinn IW, Neuberg DS, Paietta EM, Bennett JM, Jelinek DF, Gribben JG, Hussein MA, Appelbaum FR, Larson RA, Moore DF, Tallman MS, Byrd JC, Grever MR. Cytogenetic prioritization with inclusion of molecular markers predicts outcome in previously untreated patients with chronic lymphocytic leukemia treated with fludarabine or fludarabine plus cyclophosphamide: a long-term follow-up study of the US intergroup phase III trial E2997. Leuk Lymphoma 2015; 56:3031-7. [PMID: 25721902 DOI: 10.3109/10428194.2015.1023800] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fludarabine (F) and cyclophosphamide (C) remain backbones of up-front chemotherapy regimens for chronic lymphocytic leukemia (CLL). We report long-term follow-up of a randomized F vs. FC trial in untreated CLL (#) . With median follow-up of 88 months, estimated median progression-free survival (PFS) was 19.3 vs. 48.1 months for F (n = 109) and FC (n = 118), respectively (p < 0.0001), and median overall survival (OS) was 88.0 vs. 79.1 months (p = 0.96). In multivariable analyses, variables associated with inferior PFS and OS respectively were age (p = 0.002, p < 0.001), Rai stage (p = 0.006, p = 0.02) and sex (p = 0.03, PFS only). Del(17)(p13.1) predicted shorter PFS and OS (p < 0.0001 for each), as did del(11q)(22.3) (p < 0.0001, p = 0.005, respectively), trisomy 12 with mutated Notch1 (p = 0.003, p = 0.03, respectively) and unmutated IGHV (p = 0.009, p = 0.002, respectively), all relative to patients without these features. These data confirm results from shorter follow-up and further justify targeted therapies for CLL.
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Affiliation(s)
- David M Lucas
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Amy S Ruppert
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Gerard Lozanski
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | | | - Arletta Lozanski
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Rainer Claus
- c University of Freiburg Medical Center , Freiburg , Germany.,d German Cancer Research Center , Heidelberg , Germany
| | | | - Ian W Flinn
- e Sarah Cannon Research Institute and Tennessee Oncology , Nashville , TN , USA
| | | | | | | | | | - John G Gribben
- i Barts Cancer Institute, Queen Mary University of London , London , UK
| | | | | | | | | | | | - John C Byrd
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Michael R Grever
- a Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
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Dinaciclib is a novel cyclin-dependent kinase inhibitor with significant clinical activity in relapsed and refractory chronic lymphocytic leukemia. Leukemia 2015; 29:1524-9. [PMID: 25708835 PMCID: PMC4551390 DOI: 10.1038/leu.2015.31] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/08/2014] [Accepted: 12/11/2014] [Indexed: 02/06/2023]
Abstract
Dinaciclib (SCH727965) is a selective CDKi chosen for clinical development based upon a favorable therapeutic index in cancer xenograft models. We performed a phase I dose escalation study of dinaciclib in relapsed and refractory CLL patients with intact organ function and WBC < 200 × 109/L. Five separate dose levels (5 mg/m2, 7 mg/m2, 10 mg/m2, 14 mg/m2, and 17 mg/m2) were explored dosing on a weekly schedule × 3 with one week off (4 week cycles) using a standard 3+3 design with expansion cohorts to optimize safety. Fifty two patients were enrolled with relapsed and refractory CLL. Escalation through cohorts occurred with two DLTs at the 17 mg/m2 dose (TLS and pneumonia). The phase II expansion occurred at 14 mg/m2 with sixteen patients receiving this dose with one DLT (TLS). Additional stepped up dosing to the MTD was examined in 19 patients at this dose. Adverse events included cytopenias, transient laboratory abnormalities, and tumor lysis syndrome. Responses occurred in 28 (54%) of patients independent of del(17)(p13.1) with a median progression free survival of 481 days. Dinaciclib is clinically active in relapsed CLL including those patients with high risk del(17)(p13.1) disease and warrants future study.
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Herishanu Y, Goldschmidt N, Bairey O, Ruchlemer R, Fineman R, Rahimi-Levene N, Shvidel L, Tadmor T, Ariel A, Braester A, Shapiro M, Joffe E, Polliack A. Efficacy and safety of front-line therapy with fludarabine-cyclophosphamide-rituximab regimen for chronic lymphocytic leukemia outside clinical trials: the Israeli CLL Study Group experience. Haematologica 2015; 100:662-9. [PMID: 25661442 DOI: 10.3324/haematol.2014.115808] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 01/29/2015] [Indexed: 11/09/2022] Open
Abstract
This study aimed to evaluate the efficacy and safety of the fludarabine-cyclophosphamide-rituximab regimen for young physically fit patients with chronic lymphocytic leukemia in the "real-life" setting. We specifically focused on the impact of dose reduction on patient outcomes. The patient cohort consisted of 128 patients with chronic lymphocytic leukemia (≤ 70 years) treated at 10 Israeli centers with front-line fludarabine-cyclophosphamide-rituximab. We defined reduced chemotherapy as two-thirds or less of the total indicated dose. Patients treated with rituximab were divided into two groups and compared: those who received full dosages of 375 mg/m(2) or 500 mg/m(2), and patients given less than six cycles with either dose. Overall and clinical complete response rates (92.8% and 70.4%), as well as toxicities and overall survival (median not reached at 6 years), were similar to other reported clinical trials, but progression-free survival was shorter (42.5 months). Almost 50% of patients had some dose reduction of chemotherapy, 21% receiving less than two-thirds of the indicated dose, while close to 30% did not complete six cycles of rituximab. Reduced doses of chemotherapy and rituximab were independently associated with shorter progression-free survival (hazard ratio 3.6, P<0.0001 for reduced chemotherapy; hazard ratio 2.5, P=0.003 for incomplete-treatment with rituximab). Achieving a complete response was associated with longer overall survival but was not linked to the given dose of chemoimmunotherapy. In younger physically fit patients, front-line fludarabine-cyclophosphamide-rituximab therapy in the "real-life" setting achieves long remissions (albeit shorter than in clinical trials) and prolonged overall survival. However, dose reductions are commonly administered and may impact outcome.
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MESH Headings
- Adolescent
- Adult
- Aged
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Chromosome Aberrations
- Cyclophosphamide/administration & dosage
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Neoplasm Staging
- Retrospective Studies
- Rituximab
- Survival Analysis
- Treatment Outcome
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
- Young Adult
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31
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Thompson PA, Shpall EJ, Keating MJ. Shifting paradigms in the treatment of chronic lymphocytic leukemia. Future Oncol 2015; 11:641-57. [PMID: 25686119 DOI: 10.2217/fon.14.288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The treatment of chronic lymphocytic leukemia (CLL) is evolving rapidly. Insight into the genetics and biology of the disease, including the importance of intracellular signaling pathways and interactions with the microenvironment has led to the development of rational targeted therapies which are having a major impact on the survival of patients with relapsed and high-risk disease. In addition, an exciting array of cellular therapies and immunotherapy options are in various stages of development. We review the current understanding of CLL genetics and biology, current treatment strategies in specific patient groups and opportunities for future treatment combinations which will bring the goal of cure or long-term disease control with minimal toxicity within reach for the majority of patients.
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Maroofi F, Amini S, Roshani D, Ghaderi B, Abdi M. Different frequencies and effects of ABCB1 T3435C polymorphism on clinical and laboratory features of B cell chronic lymphocytic leukemia in Kurdish patients. Tumour Biol 2015; 36:2863-8. [DOI: 10.1007/s13277-014-2914-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 11/27/2014] [Indexed: 11/29/2022] Open
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Langerbeins P, Busch R, Anheier N, Dürig J, Bergmann M, Goebeler ME, Hurtz HJ, Stauch MB, Stilgenbauer S, Döhner H, Fink AM, Cramer P, Fischer K, Wendtner CM, Hallek M, Eichhorst B. Poor efficacy and tolerability of R-CHOP in relapsed/refractory chronic lymphocytic leukemia and Richter transformation. Am J Hematol 2014; 89:E239-43. [PMID: 25196783 DOI: 10.1002/ajh.23841] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 01/14/2023]
Abstract
This phase II trial evaluated efficacy and tolerability of R-CHOP for up to 8 courses in Richter transformation (RT) and up to 6 courses in CLL plus autoimmune cytopenia (AIC) or high-risk (HR) features. HR was defined as fludarabine-refractoriness or early relapse (<36 months) after fludarabine-based treatment; 26 patients were included as HR, 19 patients had AIC, and 15 patients had RT. In the HR cohort, overall response rate was 54%, progression-free and overall survival were 9 and 21 months. In AIC patients overall response rate was 74%, progression-free and overall-survival were 10 and 41 months, respectively, and median increase in hemoglobin was 3.4 g/L. RT patients responded in 67%, progression-free was 10 and overall survival 21 months. The most common adverse events were hematologic toxicities in 92%. Severe infections occurred in 28%. Treatment was discontinued early in 45% of all patients mainly as a result of toxicity. This trial shows that R-CHOP has no role in treating complicated CLL. R-CHOP is associated with significant toxicities and fairly low efficacy compared with almost every other CLL-regimen. In RT, it might still be used as an induction therapy before allogeneic stem cell transplantation.
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Affiliation(s)
- Petra Langerbeins
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
| | - Raymonde Busch
- Institute of Medical Statistics and Epidemiology, Technical University; Munich Germany
| | - Nadine Anheier
- Department I of Internal Medicine; Clinical Center Schwabing; Munich Germany
| | - Jan Dürig
- Department of Hematology; University Hospital Essen; Germany
| | - Manuela Bergmann
- Department I of Internal Medicine; Clinical Center Schwabing; Munich Germany
| | | | | | | | | | - Hartmut Döhner
- Department III of Internal Medicine; University Hospital; Ulm Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
| | - Paula Cramer
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
| | - Kirsten Fischer
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
| | | | - Michael Hallek
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine; Center of Integrated Oncology (CIO), and CECAD-Cluster of Excellence “Cellular Stress Responses in Aging-Associated Diseases,” University of Cologne; Germany
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Shindiapina P, Brown JR, Danilov AV. A new hope: novel therapeutic approaches to treatment of chronic lymphocytic leukaemia with defects in TP53. Br J Haematol 2014; 167:149-61. [PMID: 25040077 DOI: 10.1111/bjh.13042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic lymphocytic leukaemia (CLL) is an indolent B-cell malignancy with heterogeneous outcomes. Chromosomal abnormalities in CLL are predictive of the natural disease course; del(11q) and del(17p) are recognized as high risk genetic lesions. Del(17p) is associated with an impaired function of TP53, a key tumour suppressor, and is particularly problematic. Such patients respond poorly to chemo-immunotherapy and have significantly shorter survival compared to patients with standard and low-risk cytogenetics. While TP53 pathway defects are rare at initial diagnosis, their frequency increases in relapsed CLL. Until very recently, this group of patients represented an unmet clinical need with few therapeutic options. However, the advent of targeted therapies has expanded the drug armamentarium and introduced new hope for these highly refractory patients. Agents that target B-cell receptor signalling, BH3-mimetics and others induce apoptosis of the neoplastic B-cells in a TP53-independent manner. Their use in the clinic is associated with remarkable activity in patients with del(17p). In this review we discuss the frequency and clinical significance of del(17p) and genetic mutations leading to disrupted TP53, the putative role of other TP53 homologues, and the results of key clinical trials involving both conventional chemotherapy and novel agents.
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35
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Pallasch CP, Hallek M. Incorporating Targeted Agents Into Future Therapy of Chronic Lymphocytic Leukemia. Semin Hematol 2014; 51:235-48. [DOI: 10.1053/j.seminhematol.2014.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ghia P, Hallek M. Management of chronic lymphocytic leukemia. Haematologica 2014; 99:965-72. [PMID: 24881042 PMCID: PMC4040893 DOI: 10.3324/haematol.2013.096107] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 04/23/2014] [Indexed: 12/22/2022] Open
Abstract
In the last decade, the management of chronic lymphocytic leukemia has undergone profound changes that have been driven by an improved understanding of the biology of the disease and the approval of several new drugs. Moreover, many novel drugs are currently under evaluation for rapid approval or have been approved by regulatory agencies, further broadening the available therapeutic armamentarium for patients with chronic lymphocytic leukemia. The use of novel biological and genetic parameters combined with a careful clinical evaluation allows us to dissect some of the heterogeneity of the disease and to distinguish patients with a very mild onset and course, who often will not need any treatment, from those with an intermediate prognosis and a third group with a very aggressive course (high-risk leukemia). On this background, it becomes increasingly challenging to select the right treatment strategy. In this paper, we describe our own approach to the management of different patients with chronic lymphocytic leukemia.
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Affiliation(s)
- Paolo Ghia
- Clinical Unit of Lymphoid Malignancies and Laboratory of B Cell Neoplasia, Department of Onco-Hematology and Division of Molecular Oncology, Università Vita-Salute San Raffaele, Fondazione Centro San Raffaele, IRCCS Istituto Scientifico San Raffaele, Milano, Italy
| | - Michael Hallek
- Department I Internal Medicine, Center for Integrated Oncology Köln-Bonn, Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Germany
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Said R, Tsimberidou AM. Pharmacokinetic evaluation of vincristine for the treatment of lymphoid malignancies. Expert Opin Drug Metab Toxicol 2014; 10:483-94. [PMID: 24512004 DOI: 10.1517/17425255.2014.885016] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Vincristine is a key agent for the treatment of acute lymphoblastic leukemia (ALL) and other lymphoid malignancies. The strong antineoplastic activity of vincristine has been limited by its pharmacological characteristics. AREAS COVERED This paper reviews the role of vincristine in the treatment of lymphoid malignancies. This review summarizes its efficacy and toxicity, and focuses on the pharmacokinetic features of vincristine that affect clinical outcomes. EXPERT OPINION As a single agent, vincristine is associated with brief and incomplete responses, but in combination with other agents, vincristine has dramatically improved the outcomes of lymphoid malignancies such as ALL. Vincristine is a key drug of hyper-fractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone, an intensive chemotherapeutic regimen for the treatment of ALL, and of cyclophosphamid, adriamycin, vincristine and prednisone, which has been used extensively in the treatment of patients with aggressive or indolent lymphomas and Richter syndrome. The strong antileukemic activity of vincristine has been limited by its variable and unpredictable pharmacological characteristics, narrow therapeutic index and neurotoxicity profile. These characteristics prompted the development of liposomal vincristine, which has optimized its clinical application. Liposomal vincristine has promising antileukemic activity, and it is approved by the FDA as a single agent for the treatment of relapsed/refractory Philadelphia chromosome-negative ALL.
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Affiliation(s)
- Rabih Said
- The University of Texas MD Anderson Cancer Center, Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program) , 1515 Holcombe Blvd., Unit 455, Houston, TX 77030-3722 , USA +1 713 792 4259 ; +1 713 794 3249 ;
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Adena M, Houltram J, Mulligan SP, Todd C, Malanos G. Modelling the cost effectiveness of rituximab in chronic lymphocytic leukaemia in first-line therapy and following relapse. PHARMACOECONOMICS 2014; 32:193-207. [PMID: 24442832 DOI: 10.1007/s40273-013-0125-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The efficacy and safety of adding rituximab to fludarabine and cyclophosphamide (R-FC) for the treatment of chronic lymphocytic leukaemia (CLL) has been demonstrated in two randomised trials: CLL-8 was conducted in previously untreated patients, and REACH was conducted in previously treated patients. In both trials, progression-free survival was increased in the R-FC treatment groups compared with the FC treatment groups. In CLL-8, overall survival was also significantly increased. OBJECTIVE To develop an economic model to assess the cost effectiveness, from the Australian healthcare perspective, of rituximab when used as a treatment for both previously untreated and relapsed/refractory CLL. METHODS A Markov model with three health states (unprogressed, progressed and death) was developed to extrapolate the trial results over a 15-year time horizon. A treatment algorithm was developed with Australian haematologists to inform the treatments to be modelled. The base-case compares up to three courses of six cycles of R-FC ('first-line' treatment) followed by three courses of post-progression salvage ('Salvage') treatment (including rituximab) with three courses of FC followed by three courses of Salvage treatment (excluding rituximab). Subsequent treatments are incorporated into the model by repeating the unprogressed and progressed health states for each treatment. Time-dependent transition probabilities for the model were estimated from an analysis of individual patient data from CLL-8 and REACH. Comparisons of the hazard rates for the CLL-8 and REACH trials enabled an assessment of the impact on the transitions of receiving the same regimen as the first or second treatment, and hence inform assumptions regarding transitions for third and subsequent treatments. Costs applied in the model were based on published Australian prices in 2009. RESULTS The model predicts patients receive an average of approximately two courses of treatment, and the addition of rituximab results in an incremental gain of 0.94 quality-adjusted life-years (QALYs). The incremental cost associated with the addition of rituximab is A$40,268, and hence the cost per QALY gained (QALYG) is A$42,906. CONCLUSION Rituximab, in combination with chemotherapy, when used multiple times throughout the treatment algorithm, appears to be cost effective for CLL from the Australian healthcare perspective, with a cost/QALYG within the range generally accepted as providing value.
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MESH Headings
- Algorithms
- Antibodies, Monoclonal, Murine-Derived/administration & dosage
- Antibodies, Monoclonal, Murine-Derived/economics
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/economics
- Antineoplastic Agents/therapeutic use
- Cost-Benefit Analysis
- Disease-Free Survival
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Markov Chains
- Middle Aged
- Models, Economic
- Quality-Adjusted Life Years
- Randomized Controlled Trials as Topic
- Recurrence
- Rituximab
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Abstract
Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.
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Treatment of older patients with chronic lymphocytic leukemia: key questions and current answers. Hematology 2013; 2013:158-67. [DOI: 10.1182/asheducation-2013.1.158] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
AbstractDespite the advanced age at onset, chronic lymphocytic leukemia (CLL) shortens the life expectancy of the majority of newly diagnosed patients. The management of elderly patients with CLL is more complex than that of younger patients due to the greater frequency of comorbidities and functional impairment as well as reduced organ function. Many of the recent advances in the care of CLL patients (prognostication, more intense combination therapy regimens) are of unclear relevance for elderly patients. This review addresses 5 key questions in the management of elderly patients with CLL: (1) why is classifying the “fitness” of CLL patients necessary; (2) what criteria should be used to classify patient fitness; (3) when should elderly patients be treated; (4) how should therapy be selected for elderly patients; and (5) which therapy is best (for this patient)?
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Abstract
AbstractThe management of chronic lymphocytic leukemia (CLL) is undergoing profound changes. Several new drugs have been approved for CLL treatment (fludarabine, bendamustine, and the monoclonal antibodies alemtuzumab, rituximab, and ofatumumab) and many more drugs are in advanced clinical development to be approved for this disease. In addition, the extreme heterogeneity of the clinical course and our improved ability to foresee the prognosis of this leukemia by the use of clinical, biological, and genetic parameters now allow us to characterize patients with a very mild onset and course, an intermediate prognosis, or a very aggressive course with high-risk leukemia. Therefore, it becomes increasingly challenging to select the right treatment strategy for each condition. This article summarizes the currently available diagnostic and therapeutic tools and gives an integrated recommendation of how to manage CLL in 2013. Moreover, I propose a strategy how we might integrate the novel agents for CLL therapy into sequential treatment approaches in the near future.
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Abstract
AbstractThe management of chronic lymphocytic leukemia (CLL) is undergoing profound changes. Several new drugs have been approved for CLL treatment (fludarabine, bendamustine, and the monoclonal antibodies alemtuzumab, rituximab, and ofatumumab) and many more drugs are in advanced clinical development to be approved for this disease. In addition, the extreme heterogeneity of the clinical course and our improved ability to foresee the prognosis of this leukemia by the use of clinical, biological, and genetic parameters now allow us to characterize patients with a very mild onset and course, an intermediate prognosis, or a very aggressive course with high-risk leukemia. Therefore, it becomes increasingly challenging to select the right treatment strategy for each condition. This article summarizes the currently available diagnostic and therapeutic tools and gives an integrated recommendation of how to manage CLL in 2013. Moreover, I propose a strategy how we might integrate the novel agents for CLL therapy into sequential treatment approaches in the near future.
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Xu XX, Yan B, Wang ZX, Yu Y, Wu XX, Zhang YZ. Fludarabine-based versus CHOP-like regimens with or without rituximab in patients with previously untreated indolent lymphoma: a retrospective analysis of safety and efficacy. Onco Targets Ther 2013; 6:1385-92. [PMID: 24143112 PMCID: PMC3797259 DOI: 10.2147/ott.s47764] [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] [Indexed: 12/02/2022] Open
Abstract
Fludarabine-based regimens and CHOP (doxorubicin, cyclophosphamide, vincristine, prednisone)-like regimens with or without rituximab are the most common treatment modalities for indolent lymphoma. However, there is no clear evidence to date about which chemotherapy regimen should be the proper initial treatment of indolent lymphoma. More recently, the use of fludarabine has raised concerns due to its high number of toxicities, especially hematological toxicity and infectious complications. The present study aimed to retrospectively evaluate both the efficacy and the potential toxicities of the two main regimens (fludarabine-based and CHOP-like regimens) in patients with previously untreated indolent lymphoma. Among a total of 107 patients assessed, 54 patients received fludarabine-based regimens (FLU arm) and 53 received CHOP or CHOPE (doxorubicin, cyclophosphamide, vincristine, prednisone, or plus etoposide) regimens (CHOP arm). The results demonstrated that fludarabine-based regimens could induce significantly improved progression-free survival (PFS) compared with CHOP-like regimens. However, the FLU arm showed overall survival, complete response, and overall response rates similar to those of the CHOP arm. Grade 3–4 neutropenia occurred in 42.6% of the FLU arm and 7.5% of the CHOP arm (P < 0.000). Moreover, the FLU arm also had a higher occurrence of infection than the CHOP arm (27.8% vs 8.5%; P = 0.034). Multi-factor regression of infection revealed that only age (>60 years) and presentation of grade 3–4 myelosuppression were the independent factors to infection, and the FLU arm had significantly higher myelosuppression. In conclusion, the present study revealed that the use of fludarabine-based regimens could induce high rates of myelosuppression over CHOP-like regimens, in spite of significant increases in PFS.
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Affiliation(s)
- Xiao-Xiao Xu
- Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin
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Lukenbill J, Kalaycio M. Fludarabine: A review of the clear benefits and potential harms. Leuk Res 2013; 37:986-94. [DOI: 10.1016/j.leukres.2013.05.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 04/23/2013] [Accepted: 05/02/2013] [Indexed: 01/30/2023]
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Hallek M. Chronic lymphocytic leukemia: 2013 update on diagnosis, risk stratification and treatment. Am J Hematol 2013; 88:803-16. [PMID: 23720127 DOI: 10.1002/ajh.23491] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 05/16/2013] [Accepted: 05/17/2013] [Indexed: 12/14/2022]
Abstract
DISEASE OVERVIEW Chronic lymphocytic leukemia (CLL) is the commonest leukemia in western countries. The disease typically occurs in elderly patients and has a highly variable clinical course. Leukemic transformation is initiated by specific genomic alterations that impair apoptosis of clonal B-cells. DIAGNOSIS The diagnosis is established by blood counts, blood smears, and immunophenotyping of circulating B-lymphocytes, which identify a clonal B-cell population carrying the CD5 antigen as well as B-cell markers. PROGNOSIS Two prognostic staging systems exist, the Rai and Binet staging systems, which are established by physical examination and blood counts. Various biological and genetic markers also have prognostic value. Deletions of the short arm of chromosome 17 (del(17p)) predict resistance to most available therapies. THERAPY Patients with active or symptomatic disease or with advanced Binet or Rai stages require therapy. For physical fit patients, chemoimmunotherapy with fludarabine, cyclophosphamide and rituximab represents the current standard therapy. For unfit patients, treatment with an anti-CD20 antibody plus a milder chemotherapy (chlorambucil) is currently established as standard treatment. At relapse, the initial treatment may be repeated, if the treatment-free interval exceeds two years. If the disease relapses earlier, alternative therapies such as bendamustine alone or with rituximab, alemtuzumab, lenalidomide, or ofatumumab should be used. Patients with a del(17p) or TP53 should be considered for an allogeneic SCT. FUTURE CHALLENGES Several new agents (e.g., ibrutinib, obinutuzumab) hold the potential to change standard of CLL treatment in the next 6-12 months. Therefore, CLL patients should be included into current clinical trials whenever possible.
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Affiliation(s)
- Michael Hallek
- Department I of Internal Medicine; University of Cologne, Center for Integrated Oncology Köln Bonn, Center of Excellence on “Cellular Stress Responses in Aging-Associated Diseases,”; Germany
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Nastoupil LJ, Sinha R, Flowers CR. The role of chemotherapy in managing chronic lymphocytic leukemia: optimizing combinations with targeted therapy. Expert Rev Anticancer Ther 2013; 13:1089-108. [PMID: 23919536 DOI: 10.1586/14737140.2013.818294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
For many years, alkylating agents were the standard treatment for chronic lymphocytic leukemia (CLL). The advent of purine analogs improved response rates, but not overall survival, and although the monoclonal antibody rituximab is generally active against B-cell malignancies, it has demonstrated limited benefits as monotherapy for the treatment of CLL. However, specific combinations of chemotherapy, antibodies and targeted therapies have demonstrated additive or synergistic activity in CLL cells and deliver substantial clinical benefits. A greater understanding of the actions of chemotherapies and targeted agents on cellular pathways will advance the development of rationally designed combinations corresponding to individual patients' disease profiles.
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Affiliation(s)
- Loretta J Nastoupil
- Department of Hematology Oncology, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
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Shanafelt T, Lanasa MC, Call TG, Beaven AW, Leis JF, LaPlant B, Bowen D, Conte M, Jelinek DF, Hanson CA, Kay NE, Zent CS. Ofatumumab-based chemoimmunotherapy is effective and well tolerated in patients with previously untreated chronic lymphocytic leukemia (CLL). Cancer 2013; 119:3788-96. [PMID: 23922059 DOI: 10.1002/cncr.28292] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 06/12/2013] [Accepted: 07/02/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although rituximab-based chemoimmunotherapy (CIT) has substantially improved clinical outcomes in chronic lymphocytic leukemia (CLL), only 40% to 50% of patients achieve a complete remission (CR). There remains interest in identifying new approaches to improve the effectiveness of CIT. Ofatumumab is a fully human anti-CD20 monoclonal antibody with greater apparent single-agent activity than rituximab in CLL patients. METHODS Previously untreated CLL patients in need of therapy received 6 cycles of CIT induction with pentostatin, cyclophosphamide, and ofatumumab (PCO) followed by response assessment. RESULTS Of the 48 patients enrolled, 77% completed PCO induction. Adverse events during induction included grade 3+ hematologic toxicity (27%) and grade 3+ nonhematologic toxicity (23%). Median CD4 count after induction and 6 months later were 186 × 10(6)/L and 272 × 10(6) /L. The overall response rate was 96% (46 of 48 patients), and the CR rate was 46% (22 of 48 patients). Among the 38 patients who underwent minimal residual disease evaluation, 7 (18%) were negative for minimal residual disease. After median follow-up of 24 months, 10 (21%) patients have progressed and 8 (17%) have required retreatment. The efficacy and toxicity of ofatumumab-based CIT compare favorably to our historical trials of rituximab-based CIT using an identical chemotherapy backbone (n = 64). Time to retreatment also appeared longer for ofatumumab-based CIT (free of retreatment at 24 months: 86% [95% confidence interval = 75-99] versus 68% [95% confidence interval = 56-81] for rituximab-based CIT). CONCLUSIONS Ofatumumab-based CIT is well tolerated in patients with previously untreated CLL. The efficacy of ofatumumab-based CIT compares favorably to historical trials of rituximab-based CIT, suggesting randomized trials comparing ofatumumab-based CIT and rituximab-based CIT should be considered.
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Comparative efficacy of first-line therapies for advanced-stage chronic lymphocytic leukemia: A multiple-treatment meta-analysis. Cancer Treat Rev 2013; 39:340-9. [DOI: 10.1016/j.ctrv.2012.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/14/2012] [Accepted: 05/17/2012] [Indexed: 01/09/2023]
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Tam CS, Keating MJ. Selection of rituximab dosage in chronic lymphocytic leukemia: where is the evidence? Leuk Lymphoma 2013; 54:934-9. [PMID: 22966877 DOI: 10.3109/10428194.2012.728595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Rituximab prolongs survival in many CD20-expressing B- lymphoid malignancies. In non-Hodgkin lymphoma (NHL), a large number of clinical studies have established the 375 mg/m(2) dose of rituximab as standard. In chronic lymphocytic leukemia (CLL), response rates to single-agent rituximab at the NHL dose were low, but the use of higher doses or more frequent dosing have led to improved response rates, suggesting that a higher dose may be required. This led to the empiric decision to adopt rituximab at 500 mg/m(2) in combination with fludarabine and cyclophosphamide (FC) in phase II and III trials in CLL. The final result was the approval of rituximab at 500 mg/m(2) for treatment of CLL, in combination with FC. There is, however, preclinical evidence that full saturation of CD20 molecules may not be required to achieve chemosensitization in cancer cells, and it remains possible that the approved dose of 500 mg/m(2) is higher than what is required to achieve maximal in vivo synergy. Nevertheless, all of the randomized evidence for superiority of rituximab plus chemotherapy over chemotherapy alone comes from studies using the 500 mg/m(2) dose.
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Affiliation(s)
- Constantine S Tam
- Haematology Department, Peter MacCallum Cancer Centre, St Andrew's Place, East Melbourne, Victoria, Australia.
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