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Puckrin R, Shafey M, Storek J. The role of allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia: A review. Front Oncol 2023; 12:1105779. [PMID: 36741737 PMCID: PMC9889653 DOI: 10.3389/fonc.2022.1105779] [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: 11/23/2022] [Accepted: 12/30/2022] [Indexed: 01/20/2023] Open
Abstract
Although the use of allogeneic hematopoietic cell transplantation (HCT) for chronic lymphocytic leukemia (CLL) has declined with the development of novel targeted agents, it continues to play an important role for eligible patients with high-risk or heavily pretreated CLL who lack other treatment options. CLL is susceptible to a potent graft-versus-leukemia (GVL) effect which produces long-lasting remissions in 30-50% of transplanted patients. While allogeneic HCT is associated with significant risks of graft-versus-host disease (GVHD), infection, and non-relapse mortality (NRM), improvements in patient and donor selection, reduced intensity conditioning (RIC), GVHD prophylaxis, and supportive care have rendered this an increasingly safe and effective procedure in the current era. In this review, we discuss recent advances in allogeneic HCT for CLL, with a focus on the optimal evidence-based strategies to maximize benefit and minimize toxicity of this potentially curative cellular therapy.
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Affiliation(s)
| | | | - Jan Storek
- Department of Hematology and Hematologic Malignancies, Tom Baker Cancer Centre and University of Calgary, Calgary, AB, Canada
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2
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Linn SM, Vasudevan Nampoothiri R, Chen C, Pasic I, Al-Shaibani Z, Lam W, Law AD, Michelis FV, Kim DDH, Gerbitz A, Lipton J, Kumar R, Mattsson J, Viswabandya A. Outcomes of patients diagnosed with chronic lymphocytic leukemia after allogeneic hematopoietic stem cell transplantation: Results from a tertiary care center. Hematol Oncol Stem Cell Ther 2021; 16:230-237. [PMID: 34856195 DOI: 10.1016/j.hemonc.2021.09.008] [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: 04/21/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HCT) is currently the only curative treatment for patients with chronic lymphocytic leukemia (CLL). METHODS We analyzed the outcomes of 93 patients (median age: 52 years) who underwent allo-HCT at our center between 1989 and 2019. RESULTS After a median follow-up of 35 months, relapse was observed in 15.1% (n = 14) patients. The estimated 2-year non-relapse mortality, relapse-free survival, and overall survival (OS) were 38.1%, 54.2%, and 58.7%, respectively. The ECOG performance status ≥ 2 (hazard ratio [HR]: 4.1; p = .001) and use of total body irradiation (in a myeloablative conditioning regimen; HR: 2.64; p = .005) were predictive of poor OS after multivariable analysis. The occurrence of sinusoidal obstruction syndrome/veno-occlusive disease post-transplant was associated with poor survival (p = .001). CONCLUSION Although the use of kinase and bcl2 inhibitors may result in a decrease in the number and need of transplants, allo-HCT remains a viable option in selected patients with high-risk CLL and good performance status.
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Affiliation(s)
- Swe Mar Linn
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Ram Vasudevan Nampoothiri
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Carol Chen
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Zeyad Al-Shaibani
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Wilson Lam
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Arjun Datt Law
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Fotios V Michelis
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Dennis D H Kim
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Armin Gerbitz
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Jeffrey Lipton
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Rajat Kumar
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada.
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3
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Autologous and allogeneic hematopoietic cell transplantation for diffuse large B-cell lymphoma-type Richter syndrome. Blood Adv 2021; 5:3528-3539. [PMID: 34496026 DOI: 10.1182/bloodadvances.2021004865] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/06/2021] [Indexed: 11/20/2022] Open
Abstract
Richter syndrome (RS) represents a transformation from chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) to aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL), which is associated with a dismal prognosis. Patients with DLBCL-RS have poor outcomes with DLBCL-directed therapy; thus, consolidation with hematopoietic cell transplantation (HCT) has been used, with durable remissions observed. Studies reporting HCT outcomes in patients with DLBCL-RS have been small, have not evaluated the prognostic impact of cytogenetic risk factors, and were conducted prior to the era of novel targeted therapy of CLL/SLL. We performed a Center for International Blood and Transplant Research registry study evaluating outcomes after autologous HCT (auto-HCT; n = 53) and allogeneic HCT (allo-HCT; n = 118) in patients with DLBCL-RS treated in the modern era. More auto-HCT recipients were in complete response (CR) at HCT relative to allo-HCT recipients (66% vs 34%), whereas a higher proportion of allo-HCT recipients had 17p deletion (33% vs 7%) and had previously received novel agents (39% vs 10%). In the auto-HCT cohort, the 3-year relapse incidence, progression-free survival (PFS), and overall survival (OS) were 37%, 48%, and 57%, respectively. Among allo-HCT recipients, the 3-year relapse incidence, PFS, and OS were 30%, 43%, and 52%, respectively. In the allo-HCT cohort, deeper response at HCT was associated with outcomes (3-year PFS/OS, 66%/77% CR vs 43%/57% partial response vs 5%/15% resistant; P < .0001 for both), whereas cytogenetic abnormalities and prior novel therapy did not impact outcomes. In our study, HCT resulted in durable remissions in therapy-sensitive patients with DLBCL-RS treated in the era of targeted CLL/SLL therapy, including patients with high-risk features.
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4
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Refractory and 17p-deleted chronic lymphocytic leukemia: improving survival with pathway inhibitors and allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2020; 26:e256-e262. [PMID: 32653626 DOI: 10.1016/j.bbmt.2020.06.032] [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: 03/20/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 01/27/2023]
Abstract
Refractory/early relapsed and 17p deletion/p53 mutation (del(17p)/TP53mut)-positive chronic lymphocytic leukemia (CLL) has been conventionally considered a high-risk disease, potentially eligible for treatment with allogeneic stem cell transplantation (alloSCT). In this multicenter retrospective analysis of 157 patients, we compared the outcomes of patients with high-risk CLL treated with alloSCT, a B-cell receptor pathway inhibitor (BCRi), and both. Seventy-one patients were treated with BCRis, 67 patients underwent reduced-intensity conditioning alloSCT, and 19 received alloSCT with a BCRi before and/or after transplantation. Inverse probability of treatment weighting analyses were performed to compare the alloSCT and no-alloSCT groups; in the 2 groups, 5-year OS, PFS, and cumulative incidence of nonrelapse mortality (NRM) and relapse were 40% versus 60% (P = .096), 34% versus 17% (P = .638), 28% versus 5% (P = .016), and 38% versus 83% (P = .005), respectively. Patients treated with alloSCT plus BCRi had a 3-year OS of 83%. The 3-year OS and NRM by year of alloSCT, including patients treated with BCRi, were 53% and 17% in 2000 to 2007, 55% and 30% in 2008 to 2012, and 72% and 18% in 2013 to 2018. In conclusion, the combination of pathway inhibitors and alloSCT is feasible and may further improve the outcome of high-risk CLL patients.
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5
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How and when I do allogeneic transplant in CLL. Blood 2018; 132:31-39. [PMID: 29752258 DOI: 10.1182/blood-2018-01-785998] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 05/02/2018] [Indexed: 12/11/2022] Open
Abstract
Allogenic stem cell transplantation (allo-SCT) has been considered the treatment of choice for high-risk patients with chronic lymphocytic leukemia (CLL) and the only approach offered with curative intent in this disease. The availability novel agents, including the B-cell receptor inhibitors ibrutinib, acalabrutinib, and idelalisib, as well as venetoclax, which targets the BCL2 pathway, and the success of these agents in treating high-risk disease patients have made it more difficult to assess who should be considered for allo-SCT and when in the treatment course. In this review, I will discuss the different treatment options available for the treatment of high-risk CLL and how allo-SCT fits into the treatment algorithm in the era of novel agents.
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6
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Strati P, Jain N, O'Brien S. Chronic Lymphocytic Leukemia: Diagnosis and Treatment. Mayo Clin Proc 2018; 93:651-664. [PMID: 29728204 DOI: 10.1016/j.mayocp.2018.03.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/30/2018] [Accepted: 03/02/2018] [Indexed: 12/27/2022]
Abstract
The complexity of the treatment of patients with chronic lymphocytic leukemia has increased substantially over the past several years as a consequence of the advent of novel biological agents such as ibrutinib, idelalisib, and venetoclax, as well as increasingly potent anti-CD20 monoclonal antibodies. In addition, the identification of molecular predictive markers and the introduction of more sensitive and sophisticated techniques to assess minimal residual disease have allowed optimization of the use of chemoimmunotherapy and targeted therapies and may become standard of care in the future. This review summarizes the diagnosis, prognostication, and treatment of patients with chronic lymphocytic leukemia with emphasis on new prognostic and predictive factors and novel treatment strategies.
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MESH Headings
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Humans
- Immunotherapy/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
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Affiliation(s)
- Paolo Strati
- Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA.
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7
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Outcomes of haploidentical stem cell transplantation for chronic lymphocytic leukemia: a retrospective study on behalf of the chronic malignancies working party of the EBMT. Bone Marrow Transplant 2017; 53:255-263. [PMID: 29255169 DOI: 10.1038/s41409-017-0023-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/21/2017] [Accepted: 09/27/2017] [Indexed: 01/08/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HCT) may result in long-term disease control in high-risk chronic lymphocytic leukemia (CLL). Recently, haploidentical HCT is gaining interest because of better outcomes with post-transplantation cyclophosphamide (PTCY). We analyzed patients with CLL who received an allogeneic HCT with a haploidentical donor and whose data were available in the EBMT registry. In total 117 patients (74% males) were included; 38% received PTCY as GVHD prophylaxis. For the whole study cohort OS at 2 and 5 yrs was 48 and 38%, respectively. PFS at 2 and 5 yrs was 38 and 31%, respectively. Cumulative incidence (CI) of NRM in the whole group at 2 and 5 years were 40 and 44%, respectively. CI of relapse at 2 and 5 yrs were 22 and 26%, respectively. All outcomes were not statistically different in patients who received PTCY compared to other types of GVHD prophylaxis. In conclusion, results of haploidentical HCT in CLL seem almost identical to those with HLA-matched donors. Thereby, haploidentical HCT is an appropriate alternative in high risk CLL patients with a transplant indication but no available HLA-matched donor. Despite the use of PTCY, the CI of relapse seems not higher than observed after HLA-matched HCT.
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8
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Hill BT, Ahn KW, Hu ZH, Aljurf M, Beitinjaneh A, Cahn JY, Cerny J, Kharfan-Dabaja MA, Ganguly S, Ghosh N, Grunwald MR, Inamoto Y, Kindwall-Keller T, Nishihori T, Olsson RF, Saad A, Seftel M, Seo S, Szer J, Tallman M, Ustun C, Wiernik PH, Maziarz RT, Kalaycio M, Alyea E, Popat U, Sobecks R, Saber W. Assessment of Impact of HLA Type on Outcomes of Allogeneic Hematopoietic Stem Cell Transplantation for Chronic Lymphocytic Leukemia. Biol Blood Marrow Transplant 2017; 24:581-586. [PMID: 29032274 DOI: 10.1016/j.bbmt.2017.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/04/2017] [Indexed: 01/24/2023]
Abstract
Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy with many highly effective therapies. Chemorefractory disease, often characterized by deletion of chromosome 17p, has historically been associated with very poor outcomes, leading to the application of allogeneic hematopoietic stem cell transplantation (allo-HCT) for medically fit patients. Although the use of allo-HCT has declined since the introduction of novel targeted therapy for the treatment of CLL, there remains significant interest in understanding factors that may influence the efficacy of allo-HCT, the only known curative treatment for CLL. The potential benefit of transplantation is most likely due to the presence of alloreactive donor T cells that mediate the graft-versus-leukemia (GVL) effect. The recognition of potentially tumor-specific antigens in the context of class I and II major histocompatibility complex on malignant B lymphocytes by donor T cells may be influenced by subtle differences in the highly polymorphic HLA locus. Given previous reports of specific HLA alleles impacting the incidence of CLL and the clinical outcomes of allo-HCT for CLL, we sought to study the overall survival and progression-free survival of a large cohort of patients with CLL who underwent allo-HCT from fully HLA-matched related and unrelated donors at Center for International Blood and Marrow Transplant Research transplantation centers. We found no statistically significant association of allo-HCT outcomes in CLL based on previously reported HLA combinations. Additional study is needed to further define the immunologic features that portend a more favorable GVL effect after allo-HCT for CLL.
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Affiliation(s)
- Brian T Hill
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio.
| | - Kwang Woo Ahn
- Center for International Blood and Marrow Transplantation and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zhen-Huan Hu
- Center for International Blood and Marrow Transplantation and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | | | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Jan Cerny
- UMass Memorial Medical Center, Worcester, Massachusetts
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Siddhartha Ganguly
- Blood and Marrow Transplantation, Division of Hematology and Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Nilanjan Ghosh
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Matthew Seftel
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Canada
| | - Sachiko Seo
- Department of Hematology and Oncology, National Cancer Research Center East, Chiba, Japan
| | - Jeffrey Szer
- Department of Clinical Haematology and Bone Marrow Transplantation, Royal Melbourne Hospital, Victoria, Australia
| | - Martin Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Celalettin Ustun
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - Richard T Maziarz
- Adult Blood and Marrow Stem Cell Transplant Program, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | | | - Edwin Alyea
- Center of Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Uday Popat
- M.D. Anderson Cancer Center, Houston, Texas
| | | | - Wael Saber
- Center for International Blood and Marrow Transplantation and Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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9
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Thompson PA, Stingo F, Keating MJ, Wierda WG, O'Brien SM, Estrov Z, Ledesma C, Rezvani K, Qazilbash M, Shah N, Parmar S, Popat U, Anderlini P, Yago N, Ciurea SO, Kebriaei P, Champlin R, Shpall EJ, Hosing CM. Long-term follow-up of patients receiving allogeneic stem cell transplant for chronic lymphocytic leukaemia: mixed T-cell chimerism is associated with high relapse risk and inferior survival. Br J Haematol 2017; 177:567-577. [PMID: 28295181 DOI: 10.1111/bjh.14596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/11/2016] [Indexed: 12/01/2022]
Abstract
There is limited information regarding the immunological predictors of post-allogeneic stem cell transplant (alloSCT) outcome in chronic lymphocytic leukaemia (CLL), such as mixed T-cell chimerism. We analysed 143 consecutive patients with relapsed/refractory CLL, transplanted between 2000 and 2012, to determine the prognostic relevance of mixed chimerism post-alloSCT and the ability of post-transplant immunomodulation to treat relapse. Mixed T-cell chimerism occurred in 50% of patients at 3 months and 43% at 6 months post-alloSCT; upon 3- and 6-month landmark analysis, this was associated with inferior progression-free survival (PFS) [Hazard ratio (HR) 1·93, P = 0·003 and HR 2·58, P < 0·001] and survival (HR 1·66, P = 0·05 and HR 2·17, P < 0·001), independent of baseline patient characteristics, and a lower rate of grade II-IV acute graft-versus-host disease (GHVD) (16% vs. 52%, P < 0·001). Thirty-three patients were treated with immunomodulation for relapse post-alloSCT (immunosuppression withdrawal, n = 6, donor lymphocyte infusion, n = 27); 17 achieved complete response (CR), which predicted superior PFS (53 months vs. 10 months, P < 0·001) and survival (117 months vs. 30 months, P = 0·006). Relapsed patients with mixed chimerism had inferior response to immunomodulation; conversion to full donor chimerism was highly correlated both with CR and with the development of severe acute GVHD, which was fatal in 3/8 patients. Novel therapeutic strategies are required for patients with mixed T-cell chimerism post-alloSCT for CLL.
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MESH Headings
- Adult
- Aftercare/methods
- Aged
- Chimerism
- Epidemiologic Methods
- Female
- Graft Survival/genetics
- Graft vs Host Disease/etiology
- Humans
- Immunosuppressive Agents/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphocyte Transfusion/adverse effects
- Male
- Middle Aged
- Recurrence
- Stem Cell Transplantation/methods
- Stem Cell Transplantation/mortality
- T-Lymphocytes/physiology
- Transplantation, Homologous
- Treatment Outcome
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Francesco Stingo
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Michael J Keating
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Susan M O'Brien
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Celina Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Paolo Anderlini
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nieto Yago
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Chitra M Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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10
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Algrin C, Golmard JL, Michallet M, Reman O, Huynh A, Perrot A, Sirvent A, Plesa A, Salaun V, Béné MC, Bories D, Tournilhac O, Merle-Béral H, Leblond V, Le Garff-Tavernier M, Dhedin N. Flow cytometry minimal residual disease after allogeneic transplant for chronic lymphocytic leukemia. Eur J Haematol 2017; 98:363-370. [PMID: 27943415 DOI: 10.1111/ejh.12836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVES This study investigates whether achieving complete remission (CR) with undetectable minimal residual disease (MRD) after allogeneic stem cell transplantation (allo-SCT) for chronic lymphocytic leukemia (CLL) affects outcome. METHODS We retrospectively studied 46 patients transplanted for CLL and evaluated for post-transplant MRD by flow cytometry. RESULTS At transplant time, 43% of the patients were in CR, including one with undetectable MRD, 46% were in partial response, and 11% had refractory disease. After transplant, 61% of the patients achieved CR with undetectable MRD status. By multivariate analysis, reaching CR with undetectable MRD 12 months after transplant was the only factor associated with better progression-free survival (P = 0.02) and attaining undetectable MRD, independently of the time of negativity, was the only factor that correlated with better overall survival (P = 0.04). CONCLUSION Thus, achieving undetectable MRD status after allo-SCT for CLL is a major goal to improve post-transplant outcome.
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Affiliation(s)
- Caroline Algrin
- Hématologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, GRC n°11, GRECHY, Paris, France
| | - Jean-Louis Golmard
- Unité de Recherche Clinique, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | | | | | - Anne Huynh
- Hématologie, CHU de Toulouse, Toulouse, France
| | | | | | - Adriana Plesa
- Laboratoire d'Hématologie, CHU E. Herriot, Lyon, France
| | | | | | | | | | - Hélène Merle-Béral
- Laboratoire d'Hématologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Véronique Leblond
- Hématologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, GRC n°11, GRECHY, Paris, France
| | | | - Nathalie Dhedin
- Hématologie, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.,Unité d'Hématologie Adolescents Jeunes Adultes, Hôpital Saint-Louis, Paris, France
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11
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Barrientos JC. Sequencing of chronic lymphocytic leukemia therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:128-136. [PMID: 27913471 PMCID: PMC6142523 DOI: 10.1182/asheducation-2016.1.128] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
It is an unprecedented time for the treatment of patients with chronic lymphocytic leukemia (CLL) with the recent approval of several targeted agents for use in frontline, relapsed, refractory, and high-risk disease. Traditionally, frontline management of CLL has been a combination of chemotherapy (fludarabine, cyclophosphamide, bendamustine, or chlorambucil) with an anti-CD20 monoclonal antibody (rituximab, ofatumumab, obinutuzumab). The current landscape is rapidly evolving with the advent of therapies that demonstrate selective inhibition of important pathways necessary for CLL proliferation and survival. Despite considerable progress, much is still unknown and optimal treatment selection and sequence is still debatable. None of the new agents have been compared against each other and the impact of adding an additional agent to monotherapy is not yet fully elucidated. In routine clinical practice, the choice of therapy is based on nonrandomized comparisons, presence of comorbidities, and toxicity considerations. These recently approved drugs (ibrutinib, idelalisib, and venetoclax) are reporting excellent outcomes, including patients with high-risk disease such as 17p deletion (17p-) or TP53 mutations (TP53mut). Ibrutinib and venetoclax have been approved for use in 17p- patients (frontline and relapsed, respectively). Ibrutinib is currently moving into the frontline space given recent regulatory approvals. This review will summarize and interpret the limited therapeutic sequencing data available, highlighting the need for additional studies to optimize combination strategies and treatments after failure or discontinuation of these novel agents.
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MESH Headings
- Alanine/analogs & derivatives
- Alanine/therapeutic use
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bendamustine Hydrochloride/therapeutic use
- Cell Proliferation/drug effects
- Cell Proliferation/genetics
- Chlorambucil/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 17/genetics
- Cyclophosphamide/therapeutic use
- DNA Mutational Analysis/methods
- Disease-Free Survival
- High-Throughput Nucleotide Sequencing
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Rituximab/therapeutic use
- Smith-Magenis Syndrome/drug therapy
- Smith-Magenis Syndrome/genetics
- Smith-Magenis Syndrome/mortality
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
- Jacqueline C Barrientos
- CLL Research and Treatment Program, Department of Internal Medicine, Hofstra Northwell School of Medicine, New Hyde Park, NY
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12
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Kharfan-Dabaja MA, Kumar A, Hamadani M, Stilgenbauer S, Ghia P, Anasetti C, Dreger P, Montserrat E, Perales MA, Alyea EP, Awan FT, Ayala E, Barrientos JC, Brown JR, Castro JE, Furman RR, Gribben J, Hill BT, Mohty M, Moreno C, O'Brien S, Pavletic SZ, Pinilla-Ibarz J, Reddy NM, Sorror M, Bredeson C, Carpenter P, Savani BN. Clinical Practice Recommendations for Use of Allogeneic Hematopoietic Cell Transplantation in Chronic Lymphocytic Leukemia on Behalf of the Guidelines Committee of the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2016; 22:2117-2125. [PMID: 27660167 DOI: 10.1016/j.bbmt.2016.09.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 09/14/2016] [Indexed: 12/21/2022]
Abstract
We sought to establish clinical practice recommendations to redefine the role of allogeneic hematopoietic cell transplantation (allo-HCT) for patients with chronic lymphocytic leukemia (CLL) in an era of highly active targeted therapies. We performed a systematic review to identify prospective randomized controlled trials comparing allo-HCT against novel therapies for treatment of CLL at various disease stages. In the absence of such data, we invited physicians with expertise in allo-HCT and/or CLL to participate in developing these recommendations. We followed the Grading of Recommendations Assessment, Development and Evaluation methodology. For standard-risk CLL we recommend allo-HCT in the absence of response or if there is evidence of disease progression after B cell receptor (BCR) inhibitors. For high-risk CLL an allo-HCT is recommended after failing 2 lines of therapy and showing an objective response to BCR inhibitors or to a clinical trial. It is also recommended for patients who fail to show an objective response or progress after BCR inhibitors and receive BCL-2 inhibitors, regardless of whether an objective response is achieved. For Richter transformation, we recommend allo-HCT upon demonstration of an objective response to anthracycline-based chemotherapy. A reduced-intensity conditioning regimen is recommended whenever indicated. These recommendations highlight the rapidly changing treatment landscape of CLL. Newer therapies have disrupted prior paradigms, and allo-HCT is now relegated to later stages of relapsed or refractory CLL.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida.
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida College of Medicine, Tampa, Florida
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Paolo Ghia
- Department of Onco-Haematology and Division of Experimental Oncology, IRCCS San Raffaele Hospital and Università Vita-Salute San Raffaele, Milan, Italy
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Peter Dreger
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Emili Montserrat
- Department of Hematology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Edwin P Alyea
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Farrukh T Awan
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Ernesto Ayala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida; Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Jacqueline C Barrientos
- CLL Research and Treatment Program, Hofstra Northwell School of Medicine, New Hyde Park, New York
| | - Jennifer R Brown
- Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Januario E Castro
- University of California San Diego, Moores Cancer Center, La Jolla, California
| | - Richard R Furman
- Division of Hematology-Oncology, Weill Cornell Medical College, New York, New York
| | - John Gribben
- John Vane Cancer Centre, Charterhouse Square, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Brian T Hill
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mohamad Mohty
- Department of Haematology, Saint Antoine Hospital, University Pierre & Marie Curie, and Inserm UMRs938, Paris, France
| | - Carol Moreno
- Hospital de la Santa Creu Sant Pau, Barcelona, Spain
| | - Susan O'Brien
- The University of California Irvine Chao Family Comprehensive Cancer Center, Orange, California
| | - Steven Z Pavletic
- National Institutes of Health-National Cancer Institute Experimental Transplantation and Immunology Branch, Bethesda, Maryland
| | - Javier Pinilla-Ibarz
- Department of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida; Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Nishitha M Reddy
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mohamed Sorror
- Department of Medicine, University of Washington School of Medicine and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul Carpenter
- Department of Medicine, University of Washington School of Medicine and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bipin N Savani
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
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13
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Montserrat E, Dreger P. Treatment of Chronic Lymphocytic Leukemia With del(17p)/TP53 Mutation: Allogeneic Hematopoietic Stem Cell Transplantation or BCR-Signaling Inhibitors? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16 Suppl:S74-81. [DOI: 10.1016/j.clml.2016.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 12/15/2022]
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14
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Gill S. Planes, Trains, and Automobiles: Perspectives on CAR T Cells and Other Cellular Therapies for Hematologic Malignancies. Curr Hematol Malig Rep 2016; 11:318-25. [PMID: 27136938 PMCID: PMC5018307 DOI: 10.1007/s11899-016-0330-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hematologic oncologists now have at their disposal (or a referral away) a myriad of new options to get from point A (a patient with relapsed or poor-risk disease) to point B (potential tumor eradication and long-term disease-free survival). In this perspective piece, we discuss the putative mechanisms of action and the relative strengths and weaknesses of currently available cellular therapy approaches. Notably, while many of these approaches have been published in high impact journals, with the exception of allogeneic stem cell transplantation and of checkpoint inhibitors (PD1/PDL1 or CTLA4 blockade), the published clinical trials have mostly been early phase, uncontrolled studies. Therefore, many of the new cellular therapy approaches have yet to demonstrate incontrovertible evidence of enhanced overall survival compared with controls. Nonetheless, the science behind these is sure to advance our understanding of cancer immunology and ultimately to bring us closer to our goal of curing cancer.
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Affiliation(s)
- Saar Gill
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA.
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15
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El-Asmar J, Kharfan-Dabaja MA. Hematopoietic Cell Transplantation for Richter Syndrome. Biol Blood Marrow Transplant 2016; 22:1938-1944. [PMID: 27375122 DOI: 10.1016/j.bbmt.2016.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 06/28/2016] [Indexed: 01/11/2023]
Abstract
Treatment combining chemotherapy with immunotherapy as well as novel targeted therapies have shown limited efficacy in Richter syndrome. Overall response rates after chemoimmunotherapy range from 43% to 67%, but remissions are generally short-lived. In chronic lymphocytic leukemia (CLL), allogeneic hematopoietic cell transplantation (all-HCT) is considered a potentially curative treatment modality, yielding 3-year overall survival rates exceeding 50% and a plateau in survival curves. In Richter syndrome, efficacy of allo-HCT depends on demonstrating an objective response (complete remission or partial response) before allografting, with resulting 3-year survival rates of 41% to 75%. On the other hand, the efficacy of autologous HCT is limited, especially when considering that patients autografted for Richter syndrome might relapse with CLL in 35% of cases. Notwithstanding the scarcity of published data, we recommend that patients with Richter syndrome should be referred to transplant centers as soon as the diagnosis is confirmed to evaluate their candidacy for allo-HCT. Establishing a clonal relationship to CLL is important considering the more aggressive disease course in clonally related Richter syndrome. Moreover, achievement of a complete remission or partial response to salvage therapy must be a prerequisite before moving forward with allografting for Richter syndrome. Patients who fail to demonstrate an objective response to salvage therapy should be considered for enrollment in clinical trials.
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Affiliation(s)
- Jessica El-Asmar
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Florida.
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16
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Scarfò L, Ferreri AJM, Ghia P. Chronic lymphocytic leukaemia. Crit Rev Oncol Hematol 2016; 104:169-82. [PMID: 27370174 DOI: 10.1016/j.critrevonc.2016.06.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/01/2016] [Accepted: 06/14/2016] [Indexed: 01/11/2023] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia among the adults in the Western World. CLL (and the corresponding nodal entity small lymphocytic lymphoma, SLL) is classified as a lymphoproliferative disorder characterised by the relentless accumulation of mature B-lymphocytes showing a peculiar immunophenotype in the peripheral blood, bone marrow, lymph nodes and spleen. CLL clinical course is very heterogeneous: the majority of patients follow an indolent clinical course with no or delayed treatment need and with a prolonged survival, while others experience aggressive disease requiring early treatment followed by frequent relapses. In the last decade, the improved understanding of CLL pathogenesis shed light on premalignant conditions (i.e., monoclonal B-cell lymphocytosis, MBL), defined new prognostic and predictive markers, improving patient stratification, but also broadened the therapeutic armamentarium with novel agents, targeting fundamental signaling pathways.
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Affiliation(s)
- Lydia Scarfò
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Andrés J M Ferreri
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Paolo Ghia
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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17
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Wang L, Miao K, Fan L, Xu J, Wu H, Li J, Xu W. [Reduced intensity conditioning allogeneic hematopoietic stem cell transplantation in chronic lymphocytic leukemia (CLL) patients with the aberration of p53 gene]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:308-12. [PMID: 27093994 PMCID: PMC7343084 DOI: 10.3760/cma.j.issn.0253-2727.2016.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the effectiveness and safety of reduced intensity conditioning allogeneic hematopoietic stem cell transplantation (RIC allo-HSCT) in ultra high risk chronic lymphocytic leukemia (CLL) patients with the deletion of p53 to deepen the understanding of allo-HSCT in the treatment of CLL. METHODS In this retrospective study, a total of 4 ultra high risk CLL patients with the deletion of p53 in our center between July 2012 and Jan 2014 were enrolled. The RIC regimen was administered and the hematopoietic reconstitution, transplantation related mortality (TRM), overall survival (OS), progress free survival (PFS) were evaluated. RESULTS We registered 4 patients with the median age of 56 years (49-61 years), including 3 males and 1 female. The median mononuclear cells (MNC) and CD34(+) cells were 6.54 (2.85-14.7) × 10(8)/kg (recipient body weight) and 5.81 (2.85-7.79) × 10(6)/kg (recipient body weight), respectively. The median time of the neutrophil recovery was 11 days (range of 9-12 days), and the median time of the platelet recovery 5.5 days (range of 0-11 days). Three patients (75%) attained a full donor chimerism at day 28 after transplantation and one (25%) got a mixed chimerism of donor and recipient. During the follow-up at a median time of 26.5 months (range of 21-39 months), 2 (50%) patients developed acute graft versus host disease (aGVHD) grade I and 2 (50%) patients got CMV infection. One patient got herpes zoster virus and EB virus infections. No transplantation related mortality was found in the 4 patients. One patient who was in partial response status progressed 5 months after transplantation, and the other 3 patients remained in durable remission after allo-HSCT. CONCLUSION These results suggested that RIC allo-HSCT showed durable remission, good tolerance and acceptable toxicity, which could be a better option for the treatment of ultra high risk CLL patients with the deletion of p53 and was worth to be investigated and applied widely in future.
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Affiliation(s)
- Li Wang
- The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
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18
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Current state of hematopoietic cell transplantation in CLL as smart therapies emerge. Best Pract Res Clin Haematol 2016; 29:54-66. [DOI: 10.1016/j.beha.2016.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 06/29/2016] [Accepted: 08/04/2016] [Indexed: 11/20/2022]
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19
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Emole JN, Locke FL, Pinilla-Ibarz J. An update on current and prospective immunotherapies for chronic lymphocytic leukemia. Immunotherapy 2016; 7:455-66. [PMID: 25917633 DOI: 10.2217/imt.15.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia. Combined agent chemotherapy is the current standard front-line treatment for physically fit patients with CLL. Use of chemotherapy can be complicated by significant toxicity, especially in patients with advanced age or comorbid conditions. Moreover, patients may relapse and become refractory to further chemotherapy. Immunotherapy targets the aberrant immunological processes in CLL without the toxicity of chemotherapy. Immunotherapeutic strategies can also be combined with chemotherapy to improve response rates in this incurable disease. In this review, we evaluate current and future immune-based options in the treatment of CLL.
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Affiliation(s)
- Josephine N Emole
- Department of Malignant Hematology, H Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL 33612, USA
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20
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Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is usually diagnosed in asymptomatic patients with early-stage disease. The standard management approach is careful observation, irrespective of risk factors unless patients meet the International Workshop on CLL (IWCLL) criteria for "active disease," which requires treatment. The initial standard therapy for most patients combines an anti-CD20 antibody (such as rituximab, ofatumumab, or obinutuzumab) with chemotherapy (fludarabine/cyclophosphamide [FC], bendamustine, or chlorambucil) depending on multiple factors including the physical fitness of the patient. However, patients with very high-risk CLL because of a 17p13 deletion (17p-) with or without mutation of TP53 (17p-/TP53mut) have poor responses to chemoimmunotherapy and require alternative treatment regimens containing B-cell receptor (BCR) signaling pathway inhibitors. The BCR signaling pathway inhibitors (ibrutinib targeting Bruton's tyrosine kinase [BTK] and idelalisib targeting phosphatidyl-inositol 3-kinase delta [PI3K-delta], respectively) are currently approved for the treatment of relapsed/refractory CLL and all patients with 17p- (ibrutinib), and in combination with rituximab for relapsed/refractory patients (idelalisib). These agents offer great efficacy, even in chemotherapy refractory CLL, with increased tolerability, safety, and survival. Ongoing studies aim to determine the best therapy combinations with the goal of achieving long-term disease control and the possibility of developing a curative regimen for some patients. CLL is associated with a wide range of infectious, autoimmune, and malignant complications. These complications result in considerable morbidity and mortality that can be minimized by early detection and aggressive management. This active monitoring requires ongoing patient education, provider vigilance, and a team approach to patient care.
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Affiliation(s)
- Stephan Stilgenbauer
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
| | - Richard R Furman
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
| | - Clive S Zent
- From Ulm University, Ulm, Germany; Weill Cornell Medical College, New York, NY; University of Rochester, Rochester, NY
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Abstract
Abstract
Chronic lymphocytic leukemia (CLL) is usually diagnosed in early stage, asymptomatic patients, and, although a wealth of prognostic parameters have been identified, the standard approach is a “watch and wait” strategy irrespective of risk factors. Therapy is only indicated if “active disease” criteria (International Workshop on Chronic Lymphocytic Leukemia guidelines) are met, and the routine upfront treatment is a combination of CD20 antibody (rituximab, ofatumumab or obinutuzumab) and chemotherapy (fludarabine /cyclophosphamide, bendamustine, chlorambucil), with the choice mainly determined by physical fitness of the patient. The major subgroup in which this approach does not result into satisfactory efficacy is in CLL with 17p deletion (17p−) or TP53 mutation (TP53mut). Likewise, patients with a short initial response duration (i.e., <24-26 months) have a dismal outcome with chemoimmunotherapy salvage. Therefore, these patients have been referred to as “ultra high risk,” and, in these subgroups, novel agents such as signaling kinase inhibitors (also termed B-cell receptor signaling inhibitors; e.g., ibrutinib targeting Bruton tryosine kinase, idelalisib targeting phosphoinositide 3-kinase) and BCL2 antagonists (venetoclax, formerly ABT-199/GDC-0199) have shown dramatic efficacy. Ibrutinib and idelalisib are currently approved for the treatment of relapsed or refractory CLL or frontline treatment of 17p−/TP53mut CLL regardless of fitness. Therefore, these agents are challenging the concept of adjusting treatment to fitness and TP53 status, because they offer remarkable efficacy combined with exceptional tolerability. Nevertheless, it appears that 17p−/TP53mut retains an adverse prognostic impact, making additional improvement a primary research goal aimed at the development of the best combinations and/or sequences of these new agents, as well as prognostic and predictive markers guiding their use.
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Thompson PA, O’Brien SM, Wierda WG, Ferrajoli A, Stingo F, Smith SC, Burger JA, Estrov Z, Jain N, Kantarjian HM, Keating MJ. Complex karyotype is a stronger predictor than del(17p) for an inferior outcome in relapsed or refractory chronic lymphocytic leukemia patients treated with ibrutinib-based regimens. Cancer 2015; 121:3612-21. [PMID: 26193999 PMCID: PMC4866653 DOI: 10.1002/cncr.29566] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 05/12/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ibrutinib is active in patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). In patients treated with ibrutinib for R/R CLL, del(17p), identified by interphase fluorescence in situ hybridization (FISH), is associated with inferior progression-free survival despite equivalent initial response rates. Del(17p) is frequently associated with a complex metaphase karyotype (CKT); the prognostic significance of CKT in ibrutinib-treated patients has not been reported. METHODS This study reviewed 88 patients treated for R/R CLL at The University of Texas MD Anderson Cancer Center with investigational ibrutinib-based regimens from 2010 to 2013. Pretreatment FISH and lipopolysaccharide-stimulated metaphase cytogenetic analysis were performed on bone marrow. RESULTS An adequate pretreatment metaphase karyotype was available for 56 of the 88 patients. The karyotype was complex in 21 of the 56 cases; 17 of the 21 had del(17p) according to FISH. The overall response rate, including partial remission with persistent lymphocytosis, was 94%; 18% had complete responses. In a multivariate analysis (MVA), only CKT was significantly associated with event-free survival (EFS; hazard ratio [HR], 6.6 [95% CI 1.7-25.6]; P = .006). Fludarabine-refractory CLL (HR, 6.9 [95% CI 1.8-27.1], P = .005) and CKT (HR 5.9 [95% CI 1.6-22.2], P = .008) were independently associated with inferior overall survival (OS) in MVA. Del(17p) by FISH was not significantly associated with EFS or OS in MVA. CONCLUSIONS CKT is a powerful predictor of outcomes for ibrutinib-treated patients with R/R CLL and may be a stronger predictor of biological behavior than del(17p) by FISH. Because of their relatively poor outcomes, patients with CKT are ideal candidates for studies of consolidative treatment strategies or novel treatment combinations.
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MESH Headings
- Abnormal Karyotype
- Adenine/analogs & derivatives
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Agents/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 17/genetics
- Cytogenetic Analysis
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Piperidines
- Pyrazoles/therapeutic use
- Pyrimidines/therapeutic use
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- Philip A. Thompson
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - Susan M. O’Brien
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - William G. Wierda
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | | | - Francesco Stingo
- Department of Biostatistics, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - Susan C. Smith
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - Jan A. Burger
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - Zeev Estrov
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | - Nitin Jain
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
| | | | - Michael J. Keating
- Department of Leukemia, UT MD Anderson Cancer Center, Houston TX 77030 USA
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Chakupurakal G, Leitzke S, Langerbeins P, Schiller J, Schneider PM, Holtick U, Shimabukuro-Vornhagen A, Theurich S, Chemnitz J, Hallek M, von Bergwelt-Baildon M, Scheid C. Nonmyeloablative allogeneic stem cell transplantation for chronic lymphocytic leukaemia offers the possibility of disease control with minimal morbidity and mortality--a single institution experience. Ann Hematol 2015; 94:1717-25. [PMID: 26259502 DOI: 10.1007/s00277-015-2449-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
Allogeneic stem cell transplantation is a treatment option for patients with poor risk CLL. We conducted a retrospective analysis of all CLL patients allografted at our institution, the University Hospital of Cologne, Germany. Data was collected on 40 patients from 2004 to 2012. The mean age was 54, and the majority were male (75 %). On average, the patients were diagnosed 6 years (range 2-12) prior to transplant with an average of 4 years (range 1-8) from time of first-line therapy to transplant. The remission states at the time of transplant were complete remission (CR) (n = 4), stable disease (n = 10), partial remission (n = 20) and progressive disease (n = 6). Only reduced intensity conditioning regimens were employed. The average CD34(+) cell dose was 4.16 × 10(6)/kg. Neutrophil engraftment was seen by day +17 (range 10-23) post-transplant, and 88 % achieved 95-100 % donor chimerism by day 100. Overall survival, progression-free survival and non-relapse mortality at 2 years post-transplant were 65, 52.5 and 27.5 %, respectively. A total of 51 % of patients were found to be minimal residual disease (MRD)-negative at 1 year post-transplant. Our single-centre experience confirms the valuable role of allogeneic stem cell transplantation (allo-SCT) in the treatment of poor risk CLL patients with promising long-term survival and acceptable transplant-related mortality. The advent of newer therapeutic agents should not hinder the consideration of allo-SCT for this patient cohort as it remains the only curative option for these patients.
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Affiliation(s)
- G Chakupurakal
- Stem Cell Transplantation Program, Department of Internal Medicine, University Hospital of Cologne, Cologne, Germany,
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A drive through cellular therapy for CLL in 2015: allogeneic cell transplantation and CARs. Blood 2015; 126:478-85. [DOI: 10.1182/blood-2015-03-585091] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/09/2015] [Indexed: 12/13/2022] Open
Abstract
Abstract
Over the past decade the development of safer reduced-intensity conditioning regimens, expanded donor pools, advances in supportive care, and prevention/management of graft-versus-host disease have expanded stem cell transplantation (SCT) availability for chronic lymphocytic leukemia (CLL) patients. However, there are now increasingly active treatment options available for CLL patients with favorable toxicity profiles and convenient administration schedules. This raises the critical issue of whether or not attainment of cure remains a necessary goal. It is now less clear that treatment with curative intention and with significant toxicity is required for long-term survival in CLL. In addition, the demonstrated safety and activity of genetically modified chimeric antigen receptor (CAR) T cells present the opportunity of harnessing the power of the immune system to kill CLL cells without the need for SCT. We attempt to define the role of SCT in the era of targeted therapies and discuss questions that remain to be answered. Furthermore, we highlight the potential for exciting new cellular therapy using genetically modified anti-CD19 CAR T cells and discuss its potential to alter treatment paradigms for CLL.
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25
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Hahn M, Böttcher S, Dietrich S, Hegenbart U, Rieger M, Stadtherr P, Bondong A, Schulz R, Ritgen M, Schmitt T, Tran TH, Görner M, Herth I, Luft T, Schönland S, Witzens-Harig M, Zenz T, Kneba M, Ho AD, Dreger P. Allogeneic hematopoietic stem cell transplantation for poor-risk CLL: dissecting immune-modulating strategies for disease eradication and treatment of relapse. Bone Marrow Transplant 2015; 50:1279-85. [DOI: 10.1038/bmt.2015.150] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/21/2015] [Accepted: 05/22/2015] [Indexed: 12/21/2022]
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26
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Outcomes of Cord Blood Transplantation Using Reduced-Intensity Conditioning for Chronic Lymphocytic Leukemia: A Study on Behalf of Eurocord and Cord Blood Committee of Cellular Therapy and Immunobiology Working Party, Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation, and the Societé Française de Greffe de Moelle et Therapie Cellulaire. Biol Blood Marrow Transplant 2015; 21:1515-23. [PMID: 25958294 DOI: 10.1016/j.bbmt.2015.04.026] [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] [Received: 02/19/2015] [Accepted: 04/29/2015] [Indexed: 01/04/2023]
Abstract
Outcomes after umbilical cord blood transplantation (UCBT) for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) are unknown. We analyzed outcomes of 68 patients with poor-risk CLL/SLL who underwent reduced-intensity (RIC) UCBT from 2004 to 2012. The median age was 57 years and median follow-up 36 months; 17 patients had del 17p/p53mutation, 19 patients had fludarabine-refractory disease, 11 relapsed after autologous stem cell transplantation, 8 had diagnosis of prolymphocytic leukemia, 4 had Richter syndrome, and 8 underwent transplantation with progressive or refractory disease. The most common RIC used was cyclophosphamide, fludarabine, and total body irradiation (TBI) in 82%; 15 patients received antithymocyte globulin. Most of the cord blood grafts were HLA mismatched and 76% received a double UCBT. Median total nucleated cells collected was 4.7 × 10(7)/kg. The cumulative incidences (CI) of neutrophil and platelet engraftment were 84% and 72% at 60 and 180 days respectively; day 100 graft-versus-host disease (GVHD) (grade II to IV) was 43% and 3-year chronic GVHD was 32%. The CI of relapse, nonrelapse mortality, overall survival, and progression-free survival (PFS) at 3 years were 16%, 39%, 54%, and 45%, respectively. Fludarabine-sensitive disease at transplantation and use of low-dose TBI regimens were associated with acceptable PFS. In conclusion, use of RIC-UCBT seems to be feasible in patients with poor-risk CLL/SLL and improved outcomes were observed in patients with fludarabine-sensitive disease who received low-dose TBI regimens.
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27
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Rozovski U, Benjamini O, Jain P, Thompson PA, Wierda WG, O'Brien S, Burger JA, Ferrajoli A, Faderl S, Shpall E, Hosing C, Khouri IF, Champlin R, Keating MJ, Estrov Z. Outcomes of Patients With Chronic Lymphocytic Leukemia and Richter's Transformation After Transplantation Failure. J Clin Oncol 2015; 33:1557-63. [PMID: 25847930 DOI: 10.1200/jco.2014.58.6750] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Allogeneic stem-cell transplantation (SCT) induces long-term remission in a fraction of patients with high-risk chronic lymphocytic leukemia (CLL) or Richter's transformation (RT). Our purpose was to determine the outcomes of patients whose disease progressed after allogeneic SCT. PATIENTS AND METHODS We retrospectively analyzed the outcomes of 72 patients (52 with CLL and 20 with RT) who underwent allogeneic SCT between 1998 and 2011 and had documented progression after transplantation. Twenty-two (31%) never had a response, and 50 (69%) had a response but experienced relapse after a median of 7 months (range, 2 to 85 months). Forty-eight patients who were receiving or were candidates to receive post-SCT cell-based therapies were not included in this analysis. RESULTS The median age at time of transplantation was 58 years (range, 30 to 72 years). Sixty-two patients (86%) received more than two treatment regimens and 37 (51%) received more than three treatment regimens before SCT. Sixty-six patients (92%) had active disease at the time of transplantation. The 2- and 5-year survival rates were 67% and 38% (patients with CLL) and 36% and 0% (patients with RT). The patients who developed acute or chronic graft-versus-host disease had a longer overall survival (OS; P = .05). In a multivariable analysis, RT or low hemoglobin at the time of SCT predicted shorter OS. Chronic graft-versus-host disease and an initial response to SCT predicted longer OS. CONCLUSION Patients with CLL in whom allogeneic SCT fails may have a response to and benefit from salvage therapies, and their prognosis is relatively good.
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Affiliation(s)
- Uri Rozovski
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ohad Benjamini
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Preetesh Jain
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip A Thompson
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William G Wierda
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan A Burger
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Stefan Faderl
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Shpall
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chitra Hosing
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Issa F Khouri
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard Champlin
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael J Keating
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zeev Estrov
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
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28
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Poon ML, Fox PS, Samuels BI, O’Brien S, Jabbour E, Hsu Y, Gulbis A, Korbling M, Champlin R, Abruzzo LV, Bassett RL, Khouri IF. Allogeneic stem cell transplant in patients with chronic lymphocytic leukemia with 17p deletion: consult-transplant versus consult- no-transplant analysis. Leuk Lymphoma 2015; 56:711-5. [PMID: 24913509 PMCID: PMC4454336 DOI: 10.3109/10428194.2014.930848] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Allogeneic stem cell transplant (alloSCT) can overcome the adverse prognosis of chronic lymphocytic leukemia with 17p deletion (17p- CLL). However, its applicability remains unclear. Since 2007, our leukemia service has referred patients with 17p- CLL for alloSCT at presentation. In this study, the outcomes of these patients were reviewed retrospectively to determine whether they underwent alloSCT and why patients did not undergo alloSCT. Fifty-two patients with 17p- CLL who were referred to the transplant service from 2007 to 2010 were identified. Of these patients, 32 (62%) did not undergo alloSCT, mainly because of treatment- or disease-related complications (n = 15). The 2-year post-referral overall survival rates of the alloSCT and non-SCT groups were 64% and 25%, respectively (p = 0.001). These findings suggest that while alloSCT is an effective therapy in patients with 17p- CLL, pre-SCT complications may preclude a significant proportion of patients from undergoing the procedure.
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Affiliation(s)
- Michelle L. Poon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia S. Fox
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Barry I. Samuels
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan O’Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yvonne Hsu
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alison Gulbis
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Martin Korbling
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lynne V. Abruzzo
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roland L. Bassett
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issa F. Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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29
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Knauf W, Abenhardt W, Dörfel S, Meyer D, Grugel R, Münz M, Hartmann H, Marschner N. Routine treatment of patients with chronic lymphocytic leukaemia by office-based haematologists in Germany-data from the Prospective Tumour Registry Lymphatic Neoplasms. Hematol Oncol 2015; 33:15-22. [PMID: 24733536 PMCID: PMC4406436 DOI: 10.1002/hon.2139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/31/2014] [Accepted: 01/31/2014] [Indexed: 12/04/2022]
Abstract
Various treatment options exist for patients with chronic lymphocytic leukaemia (CLL). Clinical registries provide insight into routine treatment and identify changes in treatment over time. The Tumour Registry Lymphatic Neoplasms prospectively collects data on the treatment of patients with lymphoid B-cell neoplasm as administered by office-based haematologists in Germany. Data on patient and tumour characteristics, co-morbidities, systemic treatments, and outcome parameters are recorded. Eight hundred and six patients with CLL were recruited between May 2009 and August 2013. At the start of first-line treatment, median age was 71 years, 64% were male, and 44% had a Binet stage C disease. The most frequently used first-line/second-line regimens were bendamustine + rituximab (BR, 56%/55%), fludarabine + cyclophosphamide + rituximab (FCR, 22%/11%), and bendamustine (B, 5%/9%). Chlorambucil was used in only 7% (first-line) and 6% (second-line) of patients. Patients treated with FCR were younger and healthier than patients treated with BR. Overall, 91% of first-line treatments were successful (40% complete response). Real-life patient populations differ considerably from patients treated in randomized controlled trials. BR and FCR dominate the first-line and second-line treatments of CLL by office-based haematologists in Germany. Future analysis will investigate progression-free and overall survival times.
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Affiliation(s)
- Wolfgang Knauf
- Onkologische GemeinschaftspraxisFrankfurt am Main, Germany
| | | | | | - Dirk Meyer
- Hämatologisch-Onkologische SchwerpunktpraxisGöttingen, Germany
| | | | | | | | - Norbert Marschner
- Praxis für interdisziplinäre Onkologie & HämatologieFreiburg im Breisgau, Germany
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30
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Tam CS, Stilgenbauer S. How best to manage patients with chronic lymphocytic leuekmia with 17p deletion and/orTP53mutation? Leuk Lymphoma 2015; 56:587-93. [DOI: 10.3109/10428194.2015.1011641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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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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32
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Prognosis and therapy of chronic lymphocytic leukemia and small lymphocytic lymphoma. Cancer Treat Res 2015; 165:147-75. [PMID: 25655609 DOI: 10.1007/978-3-319-13150-4_6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by a highly variable clinical course that has guided treatment principles in as much as anti-leukemic therapy is reserved for patients with active disease. This heterogeneity is somewhat dissected by prognostic markers, many of which represent pathogenic mechanisms. Recently, the introduction of highly active targeted agents and maturing data on predictive markers may lead to more individualized therapeutic approaches. In this chapter, we review key prognostic markers, current and emerging therapy, and will attempt to outline a future "where the two may connect".
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33
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Kharfan-Dabaja MA. Predictors of outcome in reduced intensity allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia: summarizing the evidence and highlighting the limitations. Immunotherapy 2015; 7:47-56. [DOI: 10.2217/imt.14.100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Several studies have reported the prognostic significance of various clinical, genetic, biologic and molecular markers on postallogeneic hematopoietic cell transplantation outcomes such as nonrelapse mortality, relapse and survival. Notwithstanding limitations, existence of refractory/progressive disease at allografting yields worse nonrelapse mortality, more relapse and inferior overall survival. Advanced age results in higher nonrelapse mortality and increased relapse risk. Presence of poor-risk cytogenetics increases post-transplant relapse risk, but its impact on overall survival appears controversial. Developing prognostic models using large multicenter data could help better understand the effect of these and other variables on post-transplant outcomes. Newly discovered mutations as well as response (or not) to new potent therapies, such as ibrutinib or others, would likely be incorporated in such models.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood & Marrow Transplantation, H Lee Moffitt Cancer Center, 12902 Magnolia Drive, FOB-3, Tampa, FL 33612, USA
- Department of Oncologic Sciences, University of South Florida College of Medicine, 12901 Bruce B Downs Boulevard, Tampa, FL 33612, USA
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Dreger P, Schetelig J, Andersen N, Corradini P, van Gelder M, Gribben J, Kimby E, Michallet M, Moreno C, Stilgenbauer S, Montserrat E. Managing high-risk CLL during transition to a new treatment era: stem cell transplantation or novel agents? Blood 2014; 124:3841-9. [PMID: 25301705 PMCID: PMC4276025 DOI: 10.1182/blood-2014-07-586826] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/27/2014] [Indexed: 01/01/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been considered as the treatment of choice for patients with high-risk chronic lymphocytic leukemia (HR-CLL; ie, refractory to purine analogs, short response [<24 months] to chemoimmunotherapy, and/or presence of del[17p]/TP53 mutations). Currently, treatment algorithms for HR-CLL are being challenged by the introduction of novel classes of drugs. Among them, BCR signal inhibitors (BCRi) and B-cell lymphoma 2 antagonists (BCL2a) appear particularly promising. As a result of the growing body of favorable outcome data reported for BCRi/BCL2a, uncertainty is emerging on how to advise patients with HR-CLL about indication for and timing of HSCT. This article provides an overview of currently available evidence and theoretical considerations to guide this difficult decision process. Until the risks and benefits of different treatment strategies are settled, all patients with HR-CLL should be considered for treatment with BCRi/BCL2a. For patients who respond to these agents, there are 2 treatment possibilities: (1) performing an HSCT or (2) continuing treatment with the novel drug. Individual disease-specific and transplant-related risk factors, along with patient's preferences, should be taken into account when recommending one of these treatments over the other.
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Affiliation(s)
- Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Johannes Schetelig
- Department Medicine I, University of Dresden, Dresden, Germany; German Bone Marrow Donor Registry, Tübingen, Germany
| | - Niels Andersen
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Paolo Corradini
- Department Hematology and Pediatric Onco-Hematology, Istituto Nazionale dei Tumori, Milan, Italy
| | - Michel van Gelder
- Department Internal Medicine/Hematology, Maastricht University, Maastricht, The Netherlands
| | - John Gribben
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Eva Kimby
- Department of Medicine/Hematology Unit, Karolinska Institute, Huddinge, Sweden
| | | | - Carol Moreno
- Hospital de la Santa Creu Sant Pau, Barcelona, Spain
| | | | - Emili Montserrat
- Department of Hematology, Hospital Clínic, University of Barcelona, Barcelona, Spain
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35
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Innis-Shelton RD, Davis RS, Lamb L, Mineishi S. Paradigm shifts in the management of poor-risk chronic lymphocytic leukemia. Leuk Lymphoma 2014; 56:1626-35. [PMID: 25308292 DOI: 10.3109/10428194.2014.974041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
With the growing complexity of treatment options for chronic lymphocytic leukemia (CLL) and variables that influence the underlying biology of this disease, providing allogeneic stem cell transplant (alloSCT) to appropriate candidates poses a challenge for transplant physicians. Novel small molecule inhibitors hold unprecedented promise for poor-risk subgroups, which will likely alter decision-making and referral patterns for transplant. In this review, we analyze what is known and may still remain true about indications for transplant based on outcomes reported in the literature recently and over the last decade.
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Affiliation(s)
- Racquel D Innis-Shelton
- Division of Hematology and Oncology, BMT and CT Program, Department of Internal Medicine, UAB Hosptial, University of Alabama at Birmingham Comprehensive Cancer Center , Birmingham, AL , USA
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36
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El-Ghammaz AMS, Abdelwahed E, Mostafa NN, Mansour DA. De novo deletion 17p13.1 as a predictor for disease progression in chronic lymphocytic leukemia. Clin Exp Med 2014; 15:493-9. [PMID: 25300358 DOI: 10.1007/s10238-014-0317-2] [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] [Received: 05/03/2014] [Accepted: 09/30/2014] [Indexed: 12/18/2022]
Abstract
To determine the prognostic impact of de novo deletion 17p13.1 (17p-) in previously untreated chronic lymphocytic leukemia (CLL) patients, we prospectively studied the outcome of 71 treatment-naïve CLL patients. About 18.3 % of them had 17p- detected by interphase fluorescent in situ hybridization (FISH) at diagnosis. There was statistically significant difference between 17p- negative and positive patients as regards 2-year overall survival [OS] (89.7 vs. 53.8 %, respectively; P = 0.001). On the other hand, 2-year progression-free survival [PFS] was also significantly higher in 17p- negative group than in 17p- positive one (82.8 vs. 23.1 %, respectively; P < 0.001). On univariate analysis for OS, 17p- positivity was significantly associated with shorter OS (P = 0.003). However, when we performed multivariate analysis, 17p- lost its significant impact. On the other hand, 17p- positivity was a significant risk factor for PFS in both univariate and multivariate analyses [independent risk factor] (P < 0.001 and P = 0.02, respectively). So, 17p- is a predictor for disease progression, but not for survival in CLL patients.
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Affiliation(s)
- Amro M S El-Ghammaz
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Essam Abdelwahed
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Nevine N Mostafa
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Dina A Mansour
- Hematology and Bone Marrow Transplantation Unit, Internal Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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37
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Mewawalla P, Nathan S. Role of allogeneic transplantation in patients with chronic lymphocytic leukemia in the era of novel therapies: a review. Ther Adv Hematol 2014; 5:139-52. [PMID: 25324955 PMCID: PMC4199093 DOI: 10.1177/2040620714550773] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common form of adult leukemia and is characterized by a highly variable clinical course. In the past decade, several prognostic risk factors have been identified facilitating the classification of CLL into various risk groups. Patients with poor risk disease, such as poor cytogenetics or relapsing after purine-based analogues, had limited therapeutic options, with allogeneic hematopoietic cell transplantation (allo-SCT) the only known therapy with curative potential. More recently, the introduction of novel agents inhibiting the B-cell receptor pathway, and the early success with chimeric antigen receptor T cells offers an effective and relatively safe option for this poor prognostic group which holds promise in the future. Alternatively, the use of reduced intensity conditioning regimens in the allo-SCT setting has led to a significant decrease in nonrelapse mortality to 16-23%, making it an attractive therapeutic option. No recent guidelines have been developed since these novel therapies became available regarding the optimal time to allo-SCT in this patient population. The advent of these novel and highly active therapeutic agents, therefore, warrants a reappraisal of the role and timing of allo-SCT in patients with CLL. In this article, we summarize the literature regarding the novel therapeutic agents available today as well as focus on the efficacy and safety of allo-SCT.
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Affiliation(s)
- Prerna Mewawalla
- Department of Hematology/Oncology and Cell Therapy, Western Pennsylvania Cancer Institute, 4800 Friendship Ave, Pittsburgh, PA 15224, USA
| | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Division of Hematology/Oncology and Cell Therapy, Rush University Medical Center, 1725 West Harrison Street, Suite 809, Chicago, IL, USA
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38
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McClanahan F, Gribben J. Transplantation in chronic lymphocytic leukemia: does it still matter in the era of novel targeted therapies? Hematol Oncol Clin North Am 2014; 28:1055-71. [PMID: 25459179 DOI: 10.1016/j.hoc.2014.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Allogeneic stem cell transplantation (HSCT) offers the only potentially curative approach in chronic lymphocytic leukemia (CLL). However, this applies only to a minority of patients, and is associated with significant treatment-related mortality and morbidity. HSCT must therefore always be considered in view of other, potentially less toxic therapies. Several new agents demonstrate impressive and durable responses in high-risk patients who might be candidates for HSCT. Therefore the choice of HSCT versus a novel agent is one that must be gauged on a patient-by-patient basis; this will change as data mature on the use of these novel agents in CLL.
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Affiliation(s)
- Fabienne McClanahan
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London EC1M6BQ, UK; Division of Molecular Genetics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, Heidelberg 69120, Germany
| | - John Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, Charterhouse Square, London EC1M6BQ, UK.
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39
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Toze CL, Gerrie AS. CLL-clear sailing ahead for many, while rough waters remain for some. Leuk Res 2014; 38:1154-5. [PMID: 25175828 DOI: 10.1016/j.leukres.2014.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/19/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Cynthia L Toze
- Leukemia/Bone Marrow Transplant Program of British Columbia, Canada; Division of Hematology, Vancouver General Hospital and British Columbia Cancer Agency, Canada; University of British Columbia, Canada.
| | - Alina S Gerrie
- Leukemia/Bone Marrow Transplant Program of British Columbia, Canada; Lymphoma Tumour Group, Divisions of Hematology and Medical Oncology, British Columbia Cancer Agency, Canada; University of British Columbia, Canada
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40
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Sobecks RM, Leis JF, Gale RP, Ahn KW, Zhu X, Sabloff M, de Lima M, Brown JR, Inamoto Y, Hale GA, Aljurf MD, Kamble RT, Hsu JW, Pavletic SZ, Wirk B, Seftel MD, Lewis ID, Alyea EP, Cortes J, Kalaycio ME, Maziarz RT, Saber W. Outcomes of human leukocyte antigen-matched sibling donor hematopoietic cell transplantation in chronic lymphocytic leukemia: myeloablative versus reduced-intensity conditioning regimens. Biol Blood Marrow Transplant 2014; 20:1390-8. [PMID: 24880021 PMCID: PMC4174349 DOI: 10.1016/j.bbmt.2014.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/21/2014] [Indexed: 11/19/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can cure some chronic lymphocytic leukemia (CLL) subjects. This study compared outcomes of myeloablative (MA) and reduced-intensity conditioning (RIC) transplants from HLA-matched sibling donors (MSD) for CLL. From 1995 to 2007, information regarding 297 CLL subjects was reported to the Center of International Blood and Marrow Transplant Research; of these, 163 underwent MA and 134 underwent RIC MSD HCT. The MA subjects underwent transplantation less often after 2000 and less commonly received antithymocyte globulin (4% versus 13%, P = .004) or prior antibody therapy (14% versus 53%; P < .001). RIC was associated with a greater likelihood of platelet recovery and less grade 2 to 4 acute graft-versus-host disease compared with MA conditioning. One- and 5-year treatment-related mortality (TRM) were 24% (95% confidence intervals [CI], 16% to 33%) versus 37% (95% CI, 30% to 45%; P = .023), and 40% (95% CI, 29% to 51%) versus 54% (95% CI, 46% to 62%; P = .036), respectively, and the relapse/progression rates at 1 and 5 years were 21% (95% CI, 14% to 29%) versus 10% (95% CI, 6% to 15%; P = .020), and 35% (95% CI, 26% to 46%) versus 17% (95% CI, 12% to 24%; P = .003), respectively. MA conditioning was associated with better progression-free (PFS) (relative risk, .60; 95% CI, .37 to .97; P = .038) and 3-year survival in transplantations before 2001, but for subsequent years, RIC was associated with better PFS and survival (relative risk, 1.49 [95% CI, .92 to 2.42]; P = .10; and relative risk, 1.86 [95% CI, 1.11 to 3.13]; P = .019). Pretransplantation disease status was the most important predictor of relapse (P = .003) and PFS (P = .0007) for both forms of transplantation conditioning. MA and RIC MSD transplantations are effective for CLL. Future strategies to decrease TRM and reduce relapses are warranted.
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Affiliation(s)
- Ronald M Sobecks
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jose F Leis
- Department of Hematology/Oncology, Mayo Clinic Arizona, Phoenix, Arizona; Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert Peter Gale
- Division of Experimental Medicine, Department of Medicine, Hematology Research Centre, Imperial College London, London, United Kingdom
| | - Kwang Woo Ahn
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaochun Zhu
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mitchell Sabloff
- Divison of Hematology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marcos de Lima
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jennifer R Brown
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | - Gregory A Hale
- Department of Hematology/Oncology, All Children's Hospital, St. Petersburg, Florida
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Rammurti T Kamble
- Department of Hematology/Oncology, Baylor College of Medicine, Center for Cell and Gene Therapy, Houston, Texas
| | - Jack W Hsu
- Division of Hematology & Oncology, Department of Medicine, Shands HealthCare and University of Florida, Gainesville, Florida
| | - Steven Z Pavletic
- National Institutes of Health-National Cancer Institute Experimental Transplantation and Immunology Branch, Bethesda, Maryland
| | - Baldeep Wirk
- Stony Brook University Medical Center, Stony Brook, New York
| | - Matthew D Seftel
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ian D Lewis
- Royal Adelaide Hospital, Adelaide, Australia
| | - Edwin P Alyea
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jorge Cortes
- Department of Leukemia, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, Texas
| | - Matt E Kalaycio
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard T Maziarz
- Center for Hematologic Malignancies, Oregon Health and Science University, Portland, Oregon
| | - Wael Saber
- Department of Medicine, Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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41
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Campregher PV, Hamerschlak N. Novel Prognostic Gene Mutations Identified in Chronic Lymphocytic Leukemia and Their Impact on Clinical Practice. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:271-6. [DOI: 10.1016/j.clml.2013.12.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Revised: 12/24/2013] [Accepted: 12/26/2013] [Indexed: 01/03/2023]
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42
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Luskin M, Wertheim G, Morrissette J, Daber R, Biegel J, Wilmoth D, Kersun L, King R, Paessler M, Simon C, Aplenc R, Loren A. CLL/SLL diagnosed in an adolescent. Pediatr Blood Cancer 2014; 61:1107-10. [PMID: 24281971 DOI: 10.1002/pbc.24884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 11/05/2013] [Indexed: 11/11/2022]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a disease of older adults. Pediatric CLL/SLL is vanishingly rare in the literature. We present a case of CLL/SLL diagnosed in a 17-year-old male. The pathologic findings of this case were those of classic CLL/SLL with an ATM deletion, a characteristic genetic abnormality in CLL/SLL. Management guidelines for CLL/SLL are tailored to older adults making determination of the optimal therapy for this patient a unique challenge.
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Affiliation(s)
- Marlise Luskin
- Division of Hematology/Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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43
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Chavez JC, Kharfan-Dabaja MA, Kim J, Yue B, Dalia S, Pinilla-Ibarz J, Anasetti C, Locke FL. Genomic aberrations deletion 11q and deletion 17p independently predict for worse progression-free and overall survival after allogeneic hematopoietic cell transplantation for chronic lymphocytic leukemia. Leuk Res 2014; 38:1165-72. [PMID: 24889511 DOI: 10.1016/j.leukres.2014.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 04/04/2014] [Accepted: 04/13/2014] [Indexed: 11/26/2022]
Abstract
Chronic lymphocytic leukemia remains incurable despite availability of potent chemoimmunotherapy regimens. Allogeneic hematopoietic cell transplantation (HCT) is the only modality that offers the possibility of cure. To identify predictors of progression-free and overall survival, we evaluated outcomes of 43 consecutive patients who received an allograft for advanced CLL. The majority received a reduced intensity conditioning regimen (n=37). Donors were HLA matched-related (n=18), matched-unrelated (n=15), mismatched-unrelated (n=7), or umbilical cord blood (n=3). The median progression-free (PFS) and overall survival (OS) were 31.4 months and 46.4 months respectively. Twenty (46.5%) patients were alive and in complete remission at a median follow-up of 31.4 months. NRM was higher than previously published series for CLL, likely due to a high burden of comorbidity (22 patients with HCT-CI ≥ 2) and a high proportion receiving HLA mismatched-unrelated donor or umbilical cord blood cells. Presence of del (11q), del(17p), or progressive disease at HCT are independent predictors of worse PFS and OS. New strategies are needed to improve survival outcomes in CLL associated with poor risk cytogenetics.
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Affiliation(s)
- Julio C Chavez
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, USA; Department of Oncologic Sciences, University of South Florida, Tampa, USA
| | - Jongphil Kim
- Department of Biostatistics and Biomedical Sciences, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Binglin Yue
- Department of Biostatistics and Biomedical Sciences, H. Lee Moffitt Cancer Center, Tampa, USA
| | - Samir Dalia
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA; Department of Oncologic Sciences, University of South Florida, Tampa, USA
| | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, USA; Department of Oncologic Sciences, University of South Florida, Tampa, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, USA; Department of Oncologic Sciences, University of South Florida, Tampa, USA
| | - Frederick L Locke
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, USA; Department of Oncologic Sciences, University of South Florida, Tampa, USA.
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44
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Kharfan-Dabaja MA, Wierda WG, Cooper LJN. Immunotherapy for chronic lymphocytic leukemia in the era of BTK inhibitors. Leukemia 2014; 28:507-17. [PMID: 24157582 DOI: 10.1038/leu.2013.311] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 10/02/2013] [Indexed: 02/03/2023]
Abstract
Understanding the pathogenesis of CLL has uncovered a plethora of novel targets for human application of monoclonal antibodies, engineered T cells, or inhibitors of signal transduction pathways. The B-cell receptor signaling pathway is being actively explored as a therapeutic target in CLL. Ibrutinib, an inhibitor of Bruton's tyrosine kinase is showing impressive responses in heavily pre-treated high-risk CLL, whether alone or in combination with MoAbs or chemotherapy. Other key components of the BCR pathway, namely PI3K-δ, are also being targeted with novel therapies with promising results as well. Future trials would likely evaluate ibrutinib in the front-line setting. Moreover, improvements in allogeneic HCT mostly by continuing to reduce associated toxicity as well as incorporating cellular therapies such as autologous CLL tumor vaccines, among others, will continue to expand. This is also the case for the next generation of chimeric antigen receptor therapy for CLL once genetically modified T cells are available at broad scale and with improved efficacy. As our ability to further refine and integrate these therapies continues to improve, and we gain further knowledge from gene sequencing, we anticipate that treatment algorithms will continue to be revised to a more personalized approach to treat this disease with improved efficacy and devoid of unnecessary toxicity.
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Affiliation(s)
- M A Kharfan-Dabaja
- 1] Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA [2] Department of Oncologic Sciences, H. Lee Moffitt Cancer Center, University of South Florida College of Medicine, Tampa, FL, USA
| | - W G Wierda
- Department of Leukemia, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - L J N Cooper
- 1] Graduate School of Biomedical Sciences, University of Texas, Houston, TX, USA [2] Division of Pediatrics, MD Anderson Cancer Center, University of Texas, Houston, TX, USA
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45
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Tomblyn MR. Reprint of: A review of cellular therapies for chronic lymphocytic leukemia. Biol Blood Marrow Transplant 2014; 20:S18-S21. [PMID: 24485018 DOI: 10.1016/j.bbmt.2014.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Marcie Riches Tomblyn
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
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46
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A Review of Cellular Therapies for Chronic Lymphocytic Leukemia. Biol Blood Marrow Transplant 2014; 20:164-7. [DOI: 10.1016/j.bbmt.2013.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 11/19/2022]
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Mauro FR, Molica S, Laurenti L, Cortelezzi A, Carella AM, Zaja F, Chiarenza A, Angrilli F, Nobile F, Marasca R, Musolino C, Brugiatelli M, Piciocchi A, Vignetti M, Fazi P, Gentile G, De Propris MS, Della Starza I, Marinelli M, Chiaretti S, Del Giudice I, Nanni M, Albano F, Cuneo A, Guarini A, Foà R. Fludarabine plus alemtuzumab (FA) front-line treatment in young patients with chronic lymphocytic leukemia (CLL) and an adverse biologic profile. Leuk Res 2013; 38:198-203. [PMID: 24314589 DOI: 10.1016/j.leukres.2013.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 11/09/2013] [Accepted: 11/11/2013] [Indexed: 11/25/2022]
Abstract
In 45, ≤ 60 years old patients with CLL and an adverse biologic profile, a front-line treatment with Fludarabine and Campath (Alemtuzumab(®)) was given. The overall response rate was 75.5%, the complete response rate (CR) 24.4% with the lowest CR rates, 16.7% and 8.3%, in 11q and 17p deleted cases. The 3-year progression-free survival (PFS) and overall survival were 42.5% and 79.9%, respectively. PFS was significantly influenced by CLL duration, beta2-microglobulin, and improved by post-remissional stem cell transplantation. Front-line fludarabine and alemtuzumab showed a manageable safety profile and evidence of a benefit in a small series of CLL patients with adverse biologic features.
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Affiliation(s)
- Francesca R Mauro
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy.
| | - Stefano Molica
- Oncologia Medica, Azienda Ospedaliera Pugliese Ciaccio, Catanzaro, Italy
| | - Luca Laurenti
- Department of Hematology, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Agostino Cortelezzi
- Ematology-BMT Unit, IRCCS Ca'Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy
| | | | - Francesco Zaja
- Hematology-BMT Unit, S. Maria Misericordia Hospital, University of Udine, Italy
| | - Annalisa Chiarenza
- Department of Hematology, Hospital Ferrarotto, University of Catania, Italy
| | | | - Francesco Nobile
- Azienda Ospedaliera "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Oncology, Hematology and Respiratory Diseases, University of Modena and Reggio Emilia, Italy
| | - Caterina Musolino
- Division of Hematology, Medicinal Chemistry Section, University of Messina, Italy
| | - Maura Brugiatelli
- Department of Hematology, Azienda Ospedaliera Papardo, Messina, Italy
| | | | - Marco Vignetti
- Italian Group for Adult Hematologic Diseases (GIMEMA), Rome, Italy
| | - Paola Fazi
- Italian Group for Adult Hematologic Diseases (GIMEMA), Rome, Italy
| | - Giuseppe Gentile
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Maria S De Propris
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Irene Della Starza
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Marilisa Marinelli
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Sabina Chiaretti
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Ilaria Del Giudice
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Mauro Nanni
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Francesco Albano
- U.O. Ematologia con Trapianto, Università degli Studi Aldo Moro, Bari, Italy
| | - Antonio Cuneo
- Department of Hematology, Arcispedale Sant'Anna, Ferrara, Italy
| | - Anna Guarini
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
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Schnaiter A, Stilgenbauer S. 17p deletion in chronic lymphocytic leukemia: risk stratification and therapeutic approach. Hematol Oncol Clin North Am 2013; 27:289-301. [PMID: 23561474 DOI: 10.1016/j.hoc.2013.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Treatment of chronic lymphocytic leukemia has greatly advanced in the past few years since introduction of the fludarabine/cyclosphosphamide/rituximab regimen as first-line therapy. Nevertheless, 17p deletion represents a challenge because conventional treatment does not provide satisfactory results. 17p deletion and TP53 mutation are the major factors accounting for rapid disease progression, poor response to therapy, early relapse, and short survival. Allogeneic stem cell transplantation harbors curative potential but also considerable morbidity and mortality. Novel agents acting independently of the p53 signaling pathway, with favorable side-effect profiles, are promising. This review summarizes up-to-date knowledge about 17p deletion and the spectrum of treatment options.
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Affiliation(s)
- Andrea Schnaiter
- Department of Internal Medicine III, Ulm University, Ulm 89081, Germany
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49
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Cuthill K, Devereux S. How I treat patients with relapsed chronic lymphocytic leukaemia. Br J Haematol 2013; 163:423-35. [DOI: 10.1111/bjh.12549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/29/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Kirsty Cuthill
- Department of Haematological Medicine; Kings College; London UK
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50
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Burkhardt UE, Hainz U, Stevenson K, Goldstein NR, Pasek M, Naito M, Wu D, Ho VT, Alonso A, Hammond NN, Wong J, Sievers QL, Brusic A, McDonough SM, Zeng W, Perrin A, Brown JR, Canning CM, Koreth J, Cutler C, Armand P, Neuberg D, Lee JS, Antin JH, Mulligan RC, Sasada T, Ritz J, Soiffer RJ, Dranoff G, Alyea EP, Wu CJ. Autologous CLL cell vaccination early after transplant induces leukemia-specific T cells. J Clin Invest 2013; 123:3756-65. [PMID: 23912587 DOI: 10.1172/jci69098] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 05/31/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Patients with advanced hematologic malignancies remain at risk for relapse following reduced-intensity conditioning (RIC) allogeneic hematopoietic stem cell transplantation (allo-HSCT). We conducted a prospective clinical trial to test whether vaccination with whole leukemia cells early after transplantation facilitates the expansion of leukemia-reactive T cells and thereby enhances antitumor immunity. METHODS We enrolled 22 patients with advanced chronic lymphocytic leukemia (CLL), 18 of whom received up to 6 vaccines initiated between days 30 and 45 after transplantation. Each vaccine consisted of irradiated autologous tumor cells admixed with GM-CSF-secreting bystander cells. Serial patient PBMC samples following transplantation were collected, and the impact of vaccination on T cell activity was evaluated. RESULTS At a median follow-up of 2.9 (range, 1-4) years, the estimated 2-year progression-free and overall survival rates of vaccinated subjects were 82% (95% CI, 54%-94%) and 88% (95% CI, 59%-97%), respectively. Although vaccination only had a modest impact on recovering T cell numbers, CD8+ T cells from vaccinated patients consistently reacted against autologous tumor, but not alloantigen-bearing recipient cells with increased secretion of the effector cytokine IFN-γ, unlike T cells from nonvaccinated CLL patients undergoing allo-HSCT. Further analysis confirmed that 17% (range, 13%-33%) of CD8+ T cell clones isolated from 4 vaccinated patients by limiting dilution of bulk tumor-reactive T cells solely reacted against CLL-associated antigens. CONCLUSION Our studies suggest that autologous tumor cell vaccination is an effective strategy to advance long-term leukemia control following allo-HSCT. TRIAL REGISTRATION Clinicaltrials.gov NCT00442130. FUNDING NCI (5R21CA115043-2), NHLBI (5R01HL103532-03), and Leukemia and Lymphoma Society Translational Research Program.
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Affiliation(s)
- Ute E Burkhardt
- Cancer Vaccine Center, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA
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