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Abrisqueta P, González-Barca E, Ferrà C, Ríos-Herranz E, Fernández de la Mata M, Delgado J, Andreu R, Hernández-Rivas JÁ, Terol MJ, Navarro A, Vidriales MB, Baltasar P, De la Serna J, Ramírez Á, Ballester C, Moreno C, García-Marco JA, Córdoba R, Yáñez L, Casado LF, González M, Bosch F. Ibrutinib followed by ofatumumab consolidation in previously untreated patients with chronic lymphocytic leukemia (CLL): GELLC-7 trial from the Spanish group of CLL (GELLC). EClinicalMedicine 2024; 73:102642. [PMID: 38841711 PMCID: PMC11152604 DOI: 10.1016/j.eclinm.2024.102642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 06/07/2024] Open
Abstract
Background BTK inhibitors have been concurrently administered with anti-CD20 monoclonal antibodies (mAbs) in chronic lymphocytic leukemia (CLL). However, the optimal regimen for combining these two drugs remains pending. Methods This multi-center phase 2 study aimed to analyze whether consolidation with ofatumumab improved the response in patients with CLL receiving front-line treatment with ibrutinib. Patients received 12 cycles of ibrutinib monotherapy. Those who achieved CR after this induction were maintained on ibrutinib. Conversely, those who did not attain CR continued with ibrutinib in addition to a consolidation, which involved 7 doses of ofatumumab. The primary objective was the complete response (CR) rate at cycle 20. This study is registered within the EU Clinical Trials Register (EudraCT 2016-004937-26). Findings Between September 8, 2017, and May 21, 2018, 84 patients (median age, 69 years) were included. After completion of 12 cycles of ibrutinib (n = 80), 4 patients (5%) were in CR, 67 (84%) in partial response (PR), and 6 patients (7%) had a PR with lymphocytosis (PRL). After consolidation with ofatumumab, 20 patients improved the response from PR to CR and 6 patients with PRL obtained a PR. Seventy-one patients (85%) completed 20 cycles of treatment, with a CR rate of 24/71 (34%). According to the intention-to-treat analysis at cycle 20, the ORR was 69/84 (82.2%), with a CRR of 24/84 (28.6%). Progression-free survival and overall survival at 48-months were 89.9% (CI: 82.4-95.5) and 92.2% (CI: 85.3-97.1), respectively. Interpretation These findings underscore the potential for a consolidation strategy in CLL, wherein the addition of a mAb in patients with low tumor burden might enhance the quality of the response. Funding The study was funded by Janssen that also supplied ibrutinib, whereas ofatumumab was supplied by Novartis.
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Affiliation(s)
- Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eva González-Barca
- Department of Hematology, Instititut Catala D'Oncologia, Hospital Duran i Reynals, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Christelle Ferrà
- Department of Hematology, Instititut Catala D'Oncologia, Hospital Germans Trias i Pujol, Universitat de Vic/Universitat Central de Catalunya, Barcelona, Spain
| | | | | | - Julio Delgado
- Department of Hematology, Hospital Clínic, Barcelona, Spain
| | - Rafael Andreu
- Department of Hematology, Hospital Universitario La Fe, Valencia, Spain
| | | | - María José Terol
- Department of Hematology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Almudena Navarro
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, CIC- IBMCC (USAL-CSIC) CIBERONC, Salamanca, Spain
| | - M. Belén Vidriales
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, CIC- IBMCC (USAL-CSIC) CIBERONC, Salamanca, Spain
| | - Patricia Baltasar
- Department of Hematology, Hospital Universitario La Paz, Madrid, Spain
| | - Javier De la Serna
- Department of Hematology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ángel Ramírez
- Department of Hematology, Hospital Universtiario Central de Asturias, Oviedo, Spain
| | - Carmen Ballester
- Department of Hematology, Hospital Universitari Son Espases, Palma, Spain
| | - Carol Moreno
- Department of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Raúl Córdoba
- Department of Hematology, Fundación Jiménez Díaz, Madrid, Spain
| | - Lucrecia Yáñez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Luís Felipe Casado
- Department of Hematology, Hospital General Universitario de Toledo, Toledo, Spain
| | - Marcos González
- Department of Hematology, Hospital Universitario de Salamanca-IBSAL, CIC- IBMCC (USAL-CSIC) CIBERONC, Salamanca, Spain
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Hospital Universitari Vall d'Hebron, Barcelona, Spain
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2
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Goergen E, Al-Sawaf O. The prognostic significance of genomic complexity in patients with CLL. Leuk Lymphoma 2024; 65:873-881. [PMID: 38593054 DOI: 10.1080/10428194.2024.2333448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
Chromosomal aberrations are a common feature of cancer and can fuel cancer progression and treatment resistance. In chronic lymphocytic leukemia (CLL), the presence of multiple chromosomal aberrations is commonly referred to as "genomic complexity" or "complex karyotype"- (CKT). In the context of chemo- and chemoimmunotherapy, genomic complexity is associated with poor response to treatment and short survival, while some targeted therapies are able to mitigate its adverse prognostic impact. This article reviews currently available data and literature on the role of genomic complexity in CLL. The currently established tools to measure genomic complexity in patients with CLL are summarized and their strengths and weaknesses for routine diagnostics are evaluated. Moreover, possible definitions of CKT as an indicator for genomic complexity are discussed. Finally, data on the impact of CKT on clinical outcomes of patients with CLL are reviewed and the implications for patient stratification are presented.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Prognosis
- Chromosome Aberrations
- Genomics/methods
- Biomarkers, Tumor/genetics
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Affiliation(s)
- Ellinor Goergen
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Cologne, Germany
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3
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Mauro FR, Frustaci AM, Visentin A, Vitale C, Bartoletti M, Oltolini C, Zappulo E, Mikulska M. Severe infections in patients with chronic lymphocytic leukemia included in trials investigating BTK and BCL2 inhibitors. Crit Rev Oncol Hematol 2024; 201:104408. [PMID: 38880368 DOI: 10.1016/j.critrevonc.2024.104408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/30/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL-2 inhibitor venetoclax have significantly improved the prognosis of patients with chronic lymphocytic leukemia (CLL). However, the incidence of severe infections in patients receiving these agents needs to be better understood. Our review aimed to provide an overview of grade ≥3 infections in patients with CLL who received BTKi and venetoclax-based therapy in prospective trials. Infection rates were influenced by the age of patients and the duration of follow-up. For treatment-naive (TN) patients receiving BTKi, infection rates ranged between 11.4 % and 27.4 % and were close to 30 % in relapsed/refractory (R/R) patients. TN and R/R patients receiving fixed-duration venetoclax-based treatments showed variable rates, with maximum values around 20 %. Opportunistic and fatal infections were uncommon. In conclusion, infections remain a concern in patients with CLL receiving targeted agents. A better definition of factors increasing infection vulnerability could help identify those patients who require infection prophylaxis.
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Affiliation(s)
- Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele Milan 20090, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery University of Naples Federico II, Napoli, Italy
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL) University of Genoa, Italy; Infectious Diseases Unit IRCCS Ospedale Policlinico San Martino Genoa, Italy
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4
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Galieni P, Troiani E, Picardi P, Angelini M, Mestichelli F, Dalsass A, Maravalle D, Camaioni E, Bigazzi C, Caraffa P, Ruggieri M, Mazzotta S, Mattioli S, Angelini S. Unmutated IGHV at diagnosis in patients with early stage CLL independently predicts for shorter follow-up time to first treatment (TTFT). Leuk Res 2024; 143:107541. [PMID: 38905908 DOI: 10.1016/j.leukres.2024.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/03/2024] [Accepted: 06/12/2024] [Indexed: 06/23/2024]
Abstract
The mutational status of the IGHV gene is routinely assessed in patients with chronic lymphocytic leukaemia (CLL), since it is both prognostic of clinical outcome and predictive of response to treatment. This study evaluates the IGHV mutational status, assessed in newly diagnosed CLL patients, as a stand-alone predictor of time to first treatment (TTFT). We analysed the data of 236 CLL patients, diagnosed at our centre between January 2004 and September 2020, with a minimum follow-up period of 3.0 years, Binet A-B and Rai 0-II stages. IGHV was unmutated in 38.1 % and mutated in 61.9 % of cases. The univariate analysis showed a statistically significant difference (p < 0.001) in TTFT based on unmutated (85.2 % at 14 years, 95 % CI = 63.3-94.5 %) or mutated (41.3 % at 14 years, 95 % CI = 29.5-51.8 %) and the need for treatment at 1, 3 and 5 years was of 20.0 % vs 4.1 % (p < 0.001), 42.7 % vs 11.4 % (p < 0.001) and 55.8 % vs 20.0 % (p < 0.001) in unmutated and mutated IGHV patients, respectively. Multivariate analysis confirmed that unmutated IGHV status negatively affects TTFT (p < 0.001), in addition to high-risk genomic aberration (p = 0.025), Rai stage I (p = 0.007) and II (p-value < 0.001). The difference in TTFT based on unmutated or mutated IGHV status remains statistically significant also when considering the subgroups by the genomic aberrations and Rai stages. Our findings suggest that, with the single analysis of the IGHV mutational status at CLL diagnosis, along with clinical and laboratory data, and without karyotype and TP53 data, clinicians will have prognostic and predictive indications for the first clinical treatment and appropriate follow-up of patients.
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Affiliation(s)
- Piero Galieni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy.
| | - Emanuela Troiani
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Paola Picardi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Mario Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Francesca Mestichelli
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Alessia Dalsass
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Denise Maravalle
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Elisa Camaioni
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Catia Bigazzi
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Patrizia Caraffa
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Miriana Ruggieri
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Serena Mazzotta
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Silvia Mattioli
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
| | - Stefano Angelini
- Department of Haematology and Stem Cell Transplantation Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy
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5
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Cheson BD, Sharman JP. Current Approaches and Novel New Agents in the Treatment of Chronic Lymphocytic Leukemia. JCO Oncol Pract 2024:OP2300770. [PMID: 38848511 DOI: 10.1200/op.23.00770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 06/09/2024] Open
Abstract
The treatment of CLL has evolved from traditional chemoimmunotherapy (CIT) to an increasing number of targeted and biologic approaches. Randomized trials have demonstrated superiority of covalent bruton tyrosine kinase inhibitors (cBTKis) over CIT, and second-generation compounds such as acalabrutinib and zanubrutinib appear to have a more favorable efficacy/safety profile than ibrutinib. The noncovalent BTKi, pirtobrutinib, has shown impressive activity after failure of the cBTKis and is quite tolerable. The Bcl-2 inhibitor venetoclax plus a CD20, generally obinutuzumab, provides a high level of efficacy as initial treatment or after failure on a cBTKi, with many patients achieving a state of undetectable minimal residual disease. Promising novel approaches include BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T)-cell therapy. What is clear is that CIT is archaic, and current and future targeted approaches will continue to improve the outcome for patients with chronic lymphocytic leukemia.
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Affiliation(s)
| | - Jeff P Sharman
- Willamette Valley Cancer Institute, Medical Director of Hematology Research: Sara Cannon, Eugene, OR
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6
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Tsushima T, Sato N, Guo Y, Nakamura H, Kunisada K, Chi S, Akie K, Takahashi Y, Nakamura S, Shimada K, Ishii G, Minami Y, Yuda J. Richter transformation acquiring PLCG2 mutation during Bruton tyrosine kinase inhibitors treatment. EJHAEM 2024; 5:642-645. [PMID: 38895067 PMCID: PMC11182410 DOI: 10.1002/jha2.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/20/2024] [Accepted: 03/25/2024] [Indexed: 06/21/2024]
Affiliation(s)
- Takafumi Tsushima
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
- Department of Hematology and OncologyJapanese Red Cross Narita HospitalNaritaJapan
| | - Nobue Sato
- Pharmaceutical DepartmentNational Cancer Center Hospital EastKashiwaJapan
| | - Yong‐Mei Guo
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Hirotaka Nakamura
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Kodai Kunisada
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Song‐Gi Chi
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Kenta Akie
- Department of Clinical LaboratoriesNational Cancer Center Hospital EastKashiwaJapan
| | - Yuki Takahashi
- Department of Clinical LaboratoriesNational Cancer Center Hospital EastKashiwaJapan
| | - Saki Nakamura
- Department of Clinical LaboratoriesNational Cancer Center Hospital EastKashiwaJapan
| | - Kaoru Shimada
- Department of RadiologyNational Cancer Center Hospital EastKashiwaJapan
| | - Genichiro Ishii
- Department of PathologyNational Cancer Center Hospital EastKashiwaJapan
| | - Yosuke Minami
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
| | - Junichiro Yuda
- Department of Hematology and OncologyNational Cancer Center Hospital EastKashiwaJapan
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7
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Fürstenau M, Kater AP, Robrecht S, von Tresckow J, Zhang C, Gregor M, Thornton P, Staber PB, Tadmor T, Lindström V, Juliusson G, Janssens A, Levin MD, da Cunha-Bang C, Schneider C, Goldschmidt N, Vandenberghe E, Rossi D, Benz R, Nösslinger T, Heintel D, Poulsen CB, Christiansen I, Frederiksen H, Enggaard L, Posthuma EFM, Issa DE, Visser HPJ, Bellido M, Kutsch N, Dürig J, Stehle A, Vöhringer M, Böttcher S, Schulte C, Simon F, Fink AM, Fischer K, Holmes EE, Kreuzer KA, Ritgen M, Brüggemann M, Tausch E, Stilgenbauer S, Hallek M, Niemann CU, Eichhorst B. First-line venetoclax combinations versus chemoimmunotherapy in fit patients with chronic lymphocytic leukaemia (GAIA/CLL13): 4-year follow-up from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 2024; 25:744-759. [PMID: 38821083 DOI: 10.1016/s1470-2045(24)00196-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND In the primary analysis report of the GAIA/CLL13 trial, we found that venetoclax-obinutuzumab and venetoclax-obinutuzumab-ibrutinib improved undetectable measurable residual disease (MRD) rates and progression-free survival compared with chemoimmunotherapy in patients with previously untreated chronic lymphocytic leukaemia. However, to our knowledge, no data on direct comparisons of different venetoclax-based combinations are available. METHODS GAIA/CLL13 is an open-label, randomised, phase 3 study conducted at 159 sites in ten countries in Europe and the Middle East. Eligible patients were aged 18 years or older, with a life expectancy of at least 6 months, an Eastern Cooperative Oncology group performance status of 0-2, a cumulative illness rating scale score of 6 or lower or a single score of 4 or lower, and no TP53 aberrations. Patients were randomly assigned (1:1:1:1), with a computer-generated list stratified by age, Binet stage, and regional study group, to either chemoimmunotherapy, venetoclax-rituximab, venetoclax-obinutuzumab, or venetoclax-obinutuzumab-ibrutinib. All treatments were administered in 28-day cycles. Patients in the chemoimmunotherapy group received six cycles of treatment, with patients older than 65 years receiving intravenous bendamustine (90 mg/m2, days 1-2), whereas patients aged 65 years or younger received intravenous fludarabine (25 mg/m2, days 1-3) and intravenous cyclophosphamide (250 mg/m2, days 1-3). Intravenous rituximab (375 mg/m2, day 1 of cycle 1; 500 mg/m2, day 1 of cycles 2-6) was added to chemotherapy. In the experimental groups, patients received daily venetoclax (400 mg orally) for ten cycles after a 5-week ramp-up phase starting on day 22 of cycle 1. In the venetoclax-rituximab group, intravenous rituximab (375 mg/m2, day 1 of cycle 1; 500 mg/m2, day 1 of cycles 2-6) was added. In the obinutuzumab-containing groups, obinutuzumab was added (cycle 1: 100 mg on day 1, 900 mg on day 2, and 1000 mg on days 8 and 15; cycles 2-6: 1000 mg on day 1). In the venetoclax-obinutuzumab-ibrutinib group, daily ibrutinib (420 mg orally, from day 1 of cycle 1) was added until undetectable MRD was reached in two consecutive measurements (3 months apart) or until cycle 36. The planned treatment duration was six cycles in the chemoimmunotherapy group, 12 cycles in the venetoclax-rituximab and the venetoclax-obinutuzumab group and between 12 and 36 cycles in the venetoclax-obinutuzumab-ibrutinib group. Coprimary endpoints were the undetectable MRD rate in peripheral blood at month 15 for the comparison of venetoclax-obinutuzumab versus standard chemoimmunotherapy and investigator-assessed progression-free survival for the comparison of venetoclax-obinutuzumab-ibrutinib versus standard chemoimmunotherapy, both analysed in the intention-to-treat population (ie, all patients randomly assigned to treatment) with a split α of 0·025 for each coprimary endpoint. Both coprimary endpoints have been reported elsewhere. Here we report a post-hoc exploratory analysis of updated progression-free survival results after a 4-year follow-up of our study population. Safety analyses included all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT02950051, recruitment is complete, and all patients are off study treatment. FINDINGS Between Dec 13, 2016, and Oct 13, 2019, 1080 patients were screened and 926 were randomly assigned to treatment (chemoimmunotherapy group n=229; venetoclax-rituximab group n=237; venetoclax-obinutuzumab group n=229; and venetoclax-obinutuzumab-ibrutinib group n=231); mean age 60·8 years (SD 10·2), 259 (28%) of 926 patients were female, and 667 (72%) were male (data on race and ethnicity are not reported). At data cutoff for this exploratory follow-up analysis (Jan 31, 2023; median follow-up 50·7 months [IQR 44·6-57·9]), patients in the venetoclax-obinutuzumab group had significantly longer progression-free survival than those in the chemoimmunotherapy group (hazard ratio [HR] 0·47 [97·5% CI 0·32-0·69], p<0·0001) and the venetoclax-rituximab group (0·57 [0·38-0·84], p=0·0011). The venetoclax-obinutuzumab-ibrutinib group also had a significantly longer progression-free survival than the chemoimmunotherapy group (0·30 [0·19-0·47]; p<0·0001) and the venetoclax-rituximab group (0·38 [0·24-0·59]; p<0·0001). There was no difference in progression-free survival between the venetoclax-obinutuzumab-ibrutinib and venetoclax-obinutuzumab groups (0·63 [0·39-1·02]; p=0·031), and the proportional hazards assumption was not met for the comparison between the venetoclax-rituximab group versus the chemoimmunotherapy group (log-rank p=0·10). The estimated 4-year progression-free survival rate was 85·5% (97·5% CI 79·9-91·1; 37 [16%] events) in the venetoclax-obinutuzumab-ibrutinib group, 81·8% (75·8-87·8; 55 [24%] events) in the venetoclax-obinutuzumab group, 70·1% (63·0-77·3; 84 [35%] events) in the venetoclax-rituximab group, and 62·0% (54·4-69·7; 90 [39%] events) in the chemoimmunotherapy group. The most common grade 3 or worse treatment-related adverse event was neutropenia (114 [53%] of 216 patients in the chemoimmunotherapy group, 109 [46%] of 237 in the venetoclax-rituximab group, 127 [56%] of 228 in the venetoclax-obinutuzumab group, and 112 [48%] of 231 in the venetoclax-obinutuzumab-ibrutinib group). Deaths determined to be associated with study treatment by the investigator occurred in three (1%) patients in the chemoimmunotherapy group (n=1 due to each of sepsis, metastatic squamous cell carcinoma, and Richter's syndrome), none in the venetoclax-rituximab and venetoclax-obinutuzumab groups, and four (2%) in the venetoclax-obinutuzumab-ibrutinib group (n=1 due to each of acute myeloid leukaemia, fungal encephalitis, small-cell lung cancer, and toxic leukoencephalopathy). INTERPRETATION With more than 4 years of follow-up, venetoclax-obinutuzumab and venetoclax-obinutuzumab-ibrutinib significantly extended progression-free survival compared with both chemoimmunotherapy and venetoclax-rituximab in previously untreated, fit patients with chronic lymphocytic leukaemia, thereby supporting their use and further evaluation in this patient group, while still considering the higher toxicities observed with the triple combination. FUNDING AbbVie, Janssen, and F Hoffmann-La Roche.
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MESH Headings
- Humans
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Sulfonamides/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Female
- Aged
- Middle Aged
- Follow-Up Studies
- Piperidines/administration & dosage
- Vidarabine/analogs & derivatives
- Vidarabine/administration & dosage
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Adenine/analogs & derivatives
- Adenine/administration & dosage
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Progression-Free Survival
- Cyclophosphamide/administration & dosage
- Pyrazoles/administration & dosage
- Pyrimidines/administration & dosage
- Immunotherapy
- Adult
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Affiliation(s)
- Moritz Fürstenau
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany.
| | - Arnon P Kater
- Department of Hematology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Sandra Robrecht
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Can Zhang
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Michael Gregor
- Division of Hematology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | | | - Philipp B Staber
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Tamar Tadmor
- Hematology, Bnai-Zion Medical Center, Haifa, Israel
| | - Vesa Lindström
- Comprehensive Cancer Center, Department of Hematology, Helsinki University Hospital and University of Helsinki, Finland
| | - Gunnar Juliusson
- Department of Hematology, Skåne University Hospital, Lund, Sweden
| | - Ann Janssens
- Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Caspar da Cunha-Bang
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christof Schneider
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Neta Goldschmidt
- Department of Hematology, Hadassah Medical Center, Jerusalem, Israel
| | | | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland and Institute of Oncology Research, EOC and USI, Bellinzona, Switzerland
| | - Rudolf Benz
- Division of Hematology and Oncology, Cantonal Hospital, Münsterlingen, Switzerland
| | - Thomas Nösslinger
- Medical University of Vienna, and the Department of Hematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Daniel Heintel
- Division of Medicine I, Klinik Ottakring, Vienna, Austria
| | | | - Ilse Christiansen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | | | - Hein P J Visser
- Department of Internal Medicine, Noordwest ziekenhuisgroep, Alkmaar, Netherlands
| | - Mar Bellido
- Department of Hematology, Groningen University Medical Center, University of Groningen, Groningen, Netherlands
| | - Nadine Kutsch
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Jan Dürig
- Department of Internal Medicine, St Josef Krankenhaus Werden, University Medicine Essen, Essen, Germany
| | - Alexander Stehle
- Department of Hematology and Oncology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Matthias Vöhringer
- Department of Hematology and Oncology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
| | - Sebastian Böttcher
- Department of Medicine III Hematology, Oncology and Palliative Care, University Hospital Rostock, Rostock, Germany
| | - Clemens Schulte
- Gemeinschaftspraxis für Hämatologie und Onkologie, Dortmund, Germany
| | - Florian Simon
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Emily E Holmes
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Monika Brüggemann
- Department II of Internal Medicine, University of Schleswig-Holstein, Kiel, Germany
| | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, University of Ulm, Ulm, Germany
| | - Michael Hallek
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
| | - Carsten U Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Barbara Eichhorst
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany; German CLL Study Group, University of Cologne, Cologne, Germany
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8
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Alsouqi A, Woyach JA. Covalent Bruton's Tyrosine Kinase Inhibitors in Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00210-6. [PMID: 38897870 DOI: 10.1016/j.clml.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Inhibitors of Bruton's tyrosine kinase (BTK) are among the most widely used therapies for chronic lymphocytic leukemia (CLL) and established a new expectation for efficacy and safety in the treatment of this disease. Currently there are 3 covalent inhibitors of BTK approved for the treatment of CLL: ibrutinib, acalabrutinib, and zanubrutinib. The first-in-class covalent BTK inhibitor is ibrutinib, which as monotherapy has excellent efficacy in the front-line setting with a 7-year progression free survival (PFS) of 59%. Ibrutinib-based therapies have also demonstrated superiority over standard chemoimmunotherapy in the front-line and the relapsed/refractory setting. Acalabrutinib is a second-generation BTK inhibitor that has higher selectivity to BTK. Acalabrutinib has efficacy in both frontline and relapsed CLL and is associated with a decreased incidence of atrial fibrillation and hypertension when compared to ibrutinib. Like acalabrutinib, zanubrutinib was designed to be more selective for BTK than ibrutinib and to maximize BTK inhibition in tissues. Zanubrutinib has demonstrated clinical efficacy in first line and relapsed/refractory setting. These agents are indicated as monotherapy, with dosing until disease progression or intolerable toxicity, and are mainly differentiated by safety profile, although efficacy differences may exist as well. Combination with CD20 monoclonal antibodies and/or BCL2 inhibitors are alternative options for use. Here we will review efficacy and safety considerations with these agents.
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Affiliation(s)
- Aseel Alsouqi
- Division of Hematology and Oncology, University of Pittsburgh Medical Center- Hillman Cancer Center, Pittsburgh, PA
| | - Jennifer A Woyach
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH.
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9
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Del Giudice I, Della Starza I, De Falco F, Gaidano G, Sportoletti P. Monitoring Response and Resistance to Treatment in Chronic Lymphocytic Leukemia. Cancers (Basel) 2024; 16:2049. [PMID: 38893168 PMCID: PMC11171231 DOI: 10.3390/cancers16112049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/09/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
The recent evolution in chronic lymphocytic leukemia (CLL) targeted therapies led to a progressive change in the way clinicians manage the goals of treatment and evaluate the response to treatment in respect to the paradigm of the chemoimmunotherapy era. Continuous therapies with BTK inhibitors achieve prolonged and sustained control of the disease. On the other hand, venetoclax and anti-CD20 monoclonal antibodies or, more recently, ibrutinib plus venetoclax combinations, given for a fixed duration, achieve undetectable measurable residual disease (uMRD) in the vast majority of patients. On these grounds, a time-limited MRD-driven strategy, a previously unexplored scenario in CLL, is being attempted. On the other side of the spectrum, novel genetic and non-genetic mechanisms of resistance to targeted treatments are emerging. Here we review the response assessment criteria, the evolution and clinical application of MRD analysis and the mechanisms of resistance according to the novel treatment strategies within clinical trials. The extent to which this novel evidence will translate in the real-life management of CLL patients remains an open issue to be addressed.
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Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
| | - Irene Della Starza
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
- AIL Roma, ODV, 00161 Rome, Italy
| | - Filomena De Falco
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
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10
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Fresa A, Innocenti I, Tomasso A, Stirparo L, Mosca A, Iadevaia F, Autore F, Ghia P, Laurenti L. Treatment Sequencing in Chronic Lymphocytic Leukemia in 2024: Where We Are and Where We Are Headed. Cancers (Basel) 2024; 16:2011. [PMID: 38893131 PMCID: PMC11171037 DOI: 10.3390/cancers16112011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
As treatments with BTK inhibitors and BCL2 inhibitors have replaced the use of chemoimmunotherapy in CLL in both first-line and relapsed patients, it becomes critical to rationalize their use and exploit the full potential of each drug. Despite their proven, robust, and manifest efficacy, BTKis and BCL2is fail to provide long-term disease control in some categories of patients, and to date this is an unmet clinical need that is critical to recognize and address. Ongoing clinical trials are evaluating new treatment algorithms and new molecules to progressively thin this population. In this review for each category of patients we explicate the different possible patterns of treatment sequencing based on currently available evidence, starting from the frontline to currently ongoing trials, in order to optimize therapies as much as possible.
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Affiliation(s)
- Alberto Fresa
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Idanna Innocenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
| | - Annamaria Tomasso
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Luca Stirparo
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Antonio Mosca
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Francesco Iadevaia
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
| | - Francesco Autore
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
| | - Paolo Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Luca Laurenti
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; (A.F.); (I.I.); (F.A.)
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.T.); (L.S.); (A.M.); (F.I.)
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11
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Galitzia A, Maccaferri M, Mauro FR, Murru R, Marasca R. Chronic Lymphocytic Leukemia: Management of Adverse Events in the Era of Targeted Agents. Cancers (Basel) 2024; 16:1996. [PMID: 38893115 PMCID: PMC11171383 DOI: 10.3390/cancers16111996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
The treatment landscape for CLL has undergone a profound transformation with the advent of targeted agents (TAs) like Bruton's Tyrosine Kinase inhibitors (BTKis) and BCL-2 inhibitors (BCL-2is). These agents target crucial cellular pathways in CLL, offering superior efficacy over traditional chemo-immunotherapy, which has led to improved progression-free and overall survival rates. This advancement promises enhanced disease control and potentially normal life expectancy for many patients. However, the journey is not without challenges, as these TAs are associated with a range of adverse events (AEs) that can impact treatment efficacy and patient quality of life. This review focuses on detailing the various AEs related to TA management in CLL, evaluating their frequency and clinical impact. The aim is to present a comprehensive guide to the effective management of these AEs, ensuring optimal tolerability and efficacy of TAs. By reviewing the existing literature and consolidating findings, we provide insights into AE management, which is crucial for maximizing patient outcomes in CLL therapy.
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Affiliation(s)
- Andrea Galitzia
- Hematology and Stem Cell Transplantation Unit, Ospedale San Francesco, 08100 Nuoro, Italy;
| | - Monica Maccaferri
- Hematology Unit, Department of Oncology and Hematology, A.O.U of Modena, Policlinico, 41125 Modena, Italy; (M.M.); (R.M.)
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy;
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS G. Brotzu, 09134 Cagliari, Italy
| | - Roberto Marasca
- Hematology Unit, Department of Oncology and Hematology, A.O.U of Modena, Policlinico, 41125 Modena, Italy; (M.M.); (R.M.)
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, 41121 Modena, Italy
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12
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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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13
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Salem AH, Menon RM. Clinical pharmacokinetics and pharmacodynamics of venetoclax, a selective B-cell lymphoma-2 inhibitor. Clin Transl Sci 2024; 17:e13807. [PMID: 38778732 PMCID: PMC11112299 DOI: 10.1111/cts.13807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 05/25/2024] Open
Abstract
Venetoclax, a highly potent BCL-2 inhibitor, is indicated for treatment of some hematologic malignancies as monotherapy, and/or in combination with other agents. Venetoclax pharmacokinetics has been extensively characterized in patients and healthy participants. After oral dosing, the median time to reach maximum plasma concentration ranged from 5 to 8 h and harmonic mean half-life ranged from 14 to 18 h. Food increases venetoclax bioavailability by 3-5-fold and venetoclax should be administered with food to ensure adequate and consistent bioavailability. Venetoclax is eliminated via cytochrome P450 (CYP)3A metabolism, and a negligible amount of unchanged drug is excreted in urine. Strong CYP3A/P-glycoprotein inhibitors increased venetoclax exposures (AUC) by 1.44- to 6.90-fold while a significant decrease (71%) has been observed when dosed with strong CYP3 inducers. Venetoclax does not inhibit or induce CYP enzymes or transporters. Venetoclax pharmacokinetics is not appreciably altered by age, weight, sex, but the exposure is up to twofold higher in participants from Asian countries. Mild-to-severe renal impairment or end-stage renal disease do not alter venetoclax exposures, and venetoclax is not cleared by dialysis. Although mild-to-moderate hepatic impairment does not affect venetoclax exposures, twofold higher exposure was observed in subjects with severe hepatic impairment. Venetoclax exposure is comparable across patients with different hematologic malignancies and healthy participants. Overall, venetoclax exposure is only affected by food and CYP3A modulators and is only higher in Asian subjects and subjects with severe hepatic impairment. Venetoclax exposure-response relationships are malignancy-dependent and can be different between monotherapy and combination therapy.
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Affiliation(s)
- Ahmed Hamed Salem
- Faculty of PharmacyAin Shams UniversityCairoEgypt
- AbbVie Inc.North ChicagoIllinoisUSA
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14
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Chen X, Chen X, Zhao S, Shi Y, Zhang N, Guo Z, Qiao C, Jin H, Zhu L, Zhu H, Li J, Wu Y. Performance of a novel eight-color flow cytometry panel for measurable residual disease assessment of chronic lymphocytic leukemia. CYTOMETRY. PART B, CLINICAL CYTOMETRY 2024; 106:181-191. [PMID: 38535092 DOI: 10.1002/cyto.b.22170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Measurable residual disease (MRD) is an important prognostic indicator of chronic lymphocytic leukemia (CLL). Different flow cytometric panels have been developed for the MRD assessment of CLL in Western countries; however, the application of these panels in China remains largely unexplored. METHODS Owing to the requirements for high accuracy, reproducibility, and comparability of MRD assessment in China, we investigated the performance of a flow cytometric approach (CD45-ROR1 panel) to assess MRD in patients with CLL. The European Research Initiative on CLL (ERIC) eight-color panel was used as the "gold standard." RESULTS The sensitivity, specificity, and concordance rate of the CD45-ROR1 panel in the MRD assessment of CLL were 100% (87/87), 88.5% (23/26), and 97.3% (110/113), respectively. Two of the three inconsistent samples were further verified using next-generation sequencing. In addition, the MRD results obtained from the CD45-ROR1 panel were positively associated with the ERIC eight-color panel results for MRD assessment (R = 0.98, p < 0.0001). MRD detection at low levels (≤1.0%) demonstrated a smaller difference between the two methods (bias, -0.11; 95% CI, -0.90 to 0.68) than that at high levels (>1%). In the reproducibility assessment, the bias was smaller at three data points (within 24, 48, and 72 h) in the CD45-ROR1 panel than in the ERIC eight-color panel. Moreover, MRD levels detected using the CD45-ROR1 panel for the same samples from different laboratories showed a strong statistical correlation (R = 0.99, p < 0.0001) with trivial interlaboratory variation (bias, 0.135; 95% CI, -0.439 to 0.709). In addition, the positivity rate of MRD in the bone marrow samples was higher than that in the peripheral blood samples. CONCLUSIONS Collectively, this study demonstrated that the CD45-ROR1 panel is a reliable method for MRD assessment of CLL with high sensitivity, reproducibility, and reliability.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Flow Cytometry/methods
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/pathology
- Middle Aged
- Leukocyte Common Antigens/analysis
- Male
- Female
- Aged
- Reproducibility of Results
- Immunophenotyping/methods
- Adult
- Sensitivity and Specificity
- Aged, 80 and over
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Affiliation(s)
- Xiao Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Xia Chen
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Sishu Zhao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yu Shi
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Ninghan Zhang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Zhen Guo
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Chun Qiao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Huimin Jin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Liying Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Huayuan Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Yujie Wu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
- Key Laboratory of Hematology, Nanjing Medical University, Nanjing, China
- Department of Hematology, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
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15
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Yang L, Banerji V. Venetoclax in patients with relapsed or refractory chronic lymphocytic leukaemia. Lancet Oncol 2024; 25:413-414. [PMID: 38547887 DOI: 10.1016/s1470-2045(24)00136-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 04/02/2024]
Affiliation(s)
- Lin Yang
- CLL Clinical Care, Education and Translation Research Unit, University of Manitoba and CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada; Department of Internal Medicine, Max Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Versha Banerji
- Department of Internal Medicine, Max Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Department of Biochemistry and Medical Genetics, Max Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada; Paul Albrechtsen Research Institute, CancerCare Manitoba, Winnipeg, MB, Canada; Department of Hematology and Oncology, CancerCare Manitoba, Winnipeg, MB, Canada.
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16
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Ahn IE, Davids MS. Therapeutic targeting of apoptosis in chronic lymphocytic leukemia. Semin Hematol 2024; 61:109-118. [PMID: 38538512 DOI: 10.1053/j.seminhematol.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 06/09/2024]
Abstract
Therapeutic targeting of apoptosis with small molecule B-cell lymphoma 2 (BCL-2) inhibition with venetoclax is highly efficacious in CLL, leading to sustained deep responses, particularly among patients with treatment-naïve disease with favorable prognostic markers. Patients with unfavorable genetic characteristics such as TP53 aberration and unmutated IGHV may also derive durable benefits, but their remission duration after time-limited venetoclax-containing combination therapy is shorter, particularly in patients with relapsed/refractory disease. Emerging data indicate that the context of disease progression after initial treatment with venetoclax may define the success of re-treatment with venetoclax. Specifically, continuous venetoclax exposure may select for resistant disease due to genetic mechanisms such as BCL2 mutations and functional resistance mechanisms such as hyperphosphorylation of BCL-2 family proteins, which decrease the affinity of venetoclax binding to the target or lead to increased MCL-1 dependence and concomitant decrease in BCL-2 dependence. These patients may be best served by switching to a different class of targeted agents at the time of progression. In contrast, relapsed CLL that arises while being off therapy after a period of time-limited venetoclax-based regimens maintains sensitivity to re-treatment with venetoclax for the majority of patients. Novel strategies related to therapeutic targeting of apoptosis include next-generation BCL-2 inhibitors with improved potency and pharmacokinetic profiles, direct targeting of anti-apoptotic BH3 family proteins beyond BCL-2 such as MCL-1, and indirect targeting of MCL-1 through mechanisms such as small molecule cyclin-dependent kinase 9 inhibitors.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Apoptosis/drug effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/metabolism
- Sulfonamides/therapeutic use
- Sulfonamides/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Molecular Targeted Therapy/methods
- Drug Resistance, Neoplasm/drug effects
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Affiliation(s)
- Inhye E Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
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17
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Moia R, Gaidano G. Prognostication in chronic lymphocytic leukemia. Semin Hematol 2024; 61:83-90. [PMID: 38523019 DOI: 10.1053/j.seminhematol.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in Western countries. CLL is a highly heterogeneous disease: some patients may never require therapy and others relapse several times after different therapeutic strategies. Therefore, in CLL, prognostic markers are essential to capture high-risk patients for different clinical endpoints including early treatment requirement, early progression after BTK or BCL2 inhibitors and Richter transformation. In early stage CLL, different biological and clinical biomarkers have been identified to predict time to treatment requirement that could be used to identify the most appropriate population for early intervention clinical trial. However, at the moment, the standard of care for early stage CLL remains watch & wait since no survival benefit has been identified in clinical trials with chemoimmunotherapy and with BTK inhibitors. In patients requiring treatment TP53 disruptions identify high-risk patients who benefit the most from long-term continuous therapy with BTKi. On the opposite side of the spectrum, IGHV mutated patients devoid of TP53 disruption benefit the most from fixed-duration therapy with venetoclax-obinutuzumab. In between, the highly heterogenous subgroup of patients with IGHV unmutated genes represents the group in which further efforts are needed to identify additional prognostic biomarkers aimed at selecting patients who can benefit from fixed-duration and patients who can benefit from long term BTKi therapy. In the context of the aggressive transformation of CLL, namely Richter syndrome, the clonal relationship to the CLL counterpart represents the strongest prognostic biomarker. Clonally related Richter syndrome still represents an unmet clinical need which requires further efforts to identify new therapeutic strategies.
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MESH Headings
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Humans
- Prognosis
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/metabolism
- Mutation
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Riccardo Moia
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
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18
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Visentin A, Frazzetto S, Trentin L, Chiarenza A. Innovative Combinations, Cellular Therapies and Bispecific Antibodies for Chronic Lymphocytic Leukemia: A Narrative Review. Cancers (Basel) 2024; 16:1290. [PMID: 38610967 PMCID: PMC11011076 DOI: 10.3390/cancers16071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
In the last few years, several agents targeting molecules that sustain the survival and the proliferation of chronic lymphocytic leukemia (CLL) cells have become clinically available. Most of these drugs target surface proteins, such as CD19 or CD20, via monoclonal or bispecific monoclonal antibodies (BsAbs), CAR T cells, intracellular proteins like BTK by using covalent or non-covalent inhibitors or BCL2 with first or second generation BH3-mimetics. Since the management of CLL is evolving quickly, in this review we highlighted the most important innovative treatments including novel double and triple combination therapies, CAR T cells and BsAbs for CLL. Recently, a large number of studies on novel combinations and newer strategic options for CLL therapy have been published or presented at international conferences, which were summarized and linked together. Although the management of treatment with a single continuous agent is easier, the emergence of protein mutations, long-term toxicities and costs are important concerns that favor the use of a fixed duration therapy. In the future, a measurable residual disease (MRD)-guided treatment cessation and MRD-based re-initiation of targeted therapy seems to be a more feasible approach, allowing identification of the patients who might benefit from continuous therapy or who might need a consolidation with BsAbs or CAR T cells to clear the neoplastic clone.
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Affiliation(s)
- Andrea Visentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Sara Frazzetto
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
| | - Livio Trentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Annalisa Chiarenza
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
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19
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Hayama M, Riches JC. Taking the Next Step in Double Refractory Disease: Current and Future Treatment Strategies for Chronic Lymphocytic Leukemia. Onco Targets Ther 2024; 17:181-198. [PMID: 38476308 PMCID: PMC10929554 DOI: 10.2147/ott.s443924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a monoclonal B-cell lymphoproliferative disease with a high annual incidence in Western countries. As B-cell receptor (BCR) signaling and intrinsic apoptotic resistance play critical roles in the development and survival of CLL cells, therapeutic approaches targeting these pathways have been extensively investigated to tackle this incurable disease. Over the last decade, several Phase 3 trials have confirmed the superior efficacy of covalent Bruton tyrosine kinase inhibitors (cBTKis) and venetoclax, a selective B-cell lymphoma 2 (BCL2) inhibitor, over chemoimmunotherapy. This has been demonstrated in both the treatment-naïve and relapsed/refractory (RR) settings and includes patients with high-risk molecular features. However, these drugs are not curative, with patients continuing to relapse after treatment with both cBTKis and BCL2is, and the optimal treatment strategy for these patients has not been defined. Several novel agents with distinct mechanisms have recently been developed for CLL which have demonstrated efficacy in patients who have previously received cBTKis and BCL2i. In particular, novel BCR-signaling targeting agents have shown promising efficacy in early-phase clinical trials for RR-CLL. Furthermore, cancer immunotherapies such as bispecific antibodies and chimeric antigen receptor T-cells have also shown anti-tumor activity in patients with heavily pretreated RR-CLL. Personalised approaches with these novel agents and combination strategies based on the understanding of resistance mechanisms have the potential to overcome the clinical challenge of what to do next for a patient who has already had a cBTKi and venetoclax.
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Affiliation(s)
- Manabu Hayama
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, EC1M 6BQ, UK
| | - John C Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, EC1M 6BQ, UK
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20
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Molica S, Allsup D. Fixed-duration therapy comes of age in CLL: long-term results of MURANO and CLL14 trials. Expert Rev Anticancer Ther 2024; 24:101-106. [PMID: 38014557 DOI: 10.1080/14737140.2023.2288899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/24/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) management has witnessed a transformative shift with the advent of time-limited venetoclax and anti-CD20 monoclonal antibody (mAb) regimens, as exemplified by the groundbreaking MURANO and CLL14 trials. AREA COVERED This article delves into the long-term follow-up data of fixed duration (FD) venetoclax combined with anti-CD20 mAb across various lines of CLL therapy. The data discussed here, not yet available in current literature, was unveiled at the 23rd European Hematological Association (EHA) congress held in Frankfurt in June 2023. EXPERT OPINION Combinations of venetoclax with anti-CD20 mAbs represent a compelling therapeutic option due to their finite treatment duration and remarkable achievement of undetectable minimal residual disease (uMRD). This not only ensures more enduring responses but also presents a manageable toxicity profile that suits a broad spectrum of CLL patients, including those who are elderly or less medically fit.Importantly, the integration of venetoclax/anti-CD20 mAb FD regimens may diminish the likelihood of CLL patients developing target mutations. This, in turn, enhances the potential for eliciting secondary clinical responses upon retreatment with venetoclax. Additionally, from an economic perspective, the cost-effectiveness of targeted therapy may further advocate for the selection of FD therapy as a frontrunner in CLL treatment.
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Affiliation(s)
- Stefano Molica
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
| | - David Allsup
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
- Centre of Biomedicine, Hull York Medical School, University of Hull, Hull, UK
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21
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Nemeth K, Bayraktar R, Ferracin M, Calin GA. Non-coding RNAs in disease: from mechanisms to therapeutics. Nat Rev Genet 2024; 25:211-232. [PMID: 37968332 DOI: 10.1038/s41576-023-00662-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 11/17/2023]
Abstract
Non-coding RNAs (ncRNAs) are a heterogeneous group of transcripts that, by definition, are not translated into proteins. Since their discovery, ncRNAs have emerged as important regulators of multiple biological functions across a range of cell types and tissues, and their dysregulation has been implicated in disease. Notably, much research has focused on the link between microRNAs (miRNAs) and human cancers, although other ncRNAs, such as long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs), are also emerging as relevant contributors to human disease. In this Review, we summarize our current understanding of the roles of miRNAs, lncRNAs and circRNAs in cancer and other major human diseases, notably cardiovascular, neurological and infectious diseases. Further, we discuss the potential use of ncRNAs as biomarkers of disease and as therapeutic targets.
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Affiliation(s)
- Kinga Nemeth
- Translational Molecular Pathology Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Recep Bayraktar
- Translational Molecular Pathology Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Manuela Ferracin
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - George A Calin
- Translational Molecular Pathology Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- The RNA Interference and Non-coding RNA Center, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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22
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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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23
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Herling M, Dearden C, Zaja F, El-Sharkawi D, Ding W, Bellido M, Khot A, Tick L, Jacobsen E, Eyre TA, Roos-Weil D, Kadia T, Lucchini E, Pflug N, Davids MS, Pena G, Mukherjee N, Badawi M, Vizkelety T, Staber PB. Limited efficacy for ibrutinib and venetoclax in T-prolymphocytic leukemia: results from a phase 2 international study. Blood Adv 2024; 8:842-845. [PMID: 38190628 PMCID: PMC10874748 DOI: 10.1182/bloodadvances.2023012248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Marco Herling
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
- Department of Hematology, Cell Therapy, and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Claire Dearden
- The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Francesco Zaja
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
- DSM University of Trieste, Trieste, Italy
| | | | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mar Bellido
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - Amit Khot
- Department of Clinical Haematology, Peter MacCallum Cancer Center, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - Lidwine Tick
- Department of Internal Medicine, Máxima Medical Center, Eindhoven, The Netherlands
| | - Eric Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Toby A. Eyre
- Oxford Cancer & Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Damien Roos-Weil
- Sorbonne Université, Assistance Publique–Hôpitaux de Paris, Service Hematologie Clinique, Hopital Pitie Salpetriere, Paris, France
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elisa Lucchini
- UCO Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Natali Pflug
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - German Pena
- Department of Global Medical Affairs, Oncology, AbbVie, North Chicago, IL
| | | | - Mohamed Badawi
- Department of CPPM Clinical PK/PD, AbbVie, North Chicago, IL
| | - Tamas Vizkelety
- Department of Global Medical Affairs, Oncology, AbbVie, North Chicago, IL
| | - Philipp B. Staber
- Universitaetsklinik fuer Innere Medizin I, Klinische Abteilung fuer Haematologie und Haemostaseologie, Medizinische Universitaet Wien, Vienna, Austria
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24
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Castillo JJ, Branagan AR, Sermer D, Flynn CA, Meid K, Little M, Stockman K, White T, Canning A, Guerrera ML, Kofides A, Liu S, Liu X, Richardson K, Tsakmaklis N, Patterson CJ, Hunter ZR, Treon SP, Sarosiek S. Ibrutinib and venetoclax as primary therapy in symptomatic, treatment-naïve Waldenström macroglobulinemia. Blood 2024; 143:582-591. [PMID: 37971194 PMCID: PMC10873534 DOI: 10.1182/blood.2023022420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 11/19/2023] Open
Abstract
ABSTRACT Concurrent Bruton tyrosine kinase and BCL2 inhibition has not yet been investigated in Waldenström macroglobulinemia (WM). We performed an investigator-initiated trial of ibrutinib and venetoclax in symptomatic treatment-naïve patients with MYD88-mutated WM. Patients received ibrutinib 420 mg once daily (cycle 1), followed by a ramp-up of venetoclax to 400 mg daily (cycle 2). The combination was then administered for 22 additional 4-week cycles. The attainment of very good partial response (VGPR) was the primary end point. Forty-five patients were enrolled in this study. The median baseline characteristics were as follows: age 67 years, serum IgM 43 g/L, and hemoglobin 102 g/L. Seventeen patients (38%) carried CXCR4 mutations. Nineteen patients (42%) achieved VGPR. Grade 3 or higher adverse events included neutropenia (38%), mucositis (9%), and tumor lysis syndrome (7%). Atrial fibrillation occurred in 3 (9%), and ventricular arrhythmia in 4 (9%) patients that included 2 grade 5 events. With a median follow-up of 24.4 months, the 24-month progression-free survival (PFS) and overall survival (OS) rates were 76% and 96%, respectively, and were not impacted by CXCR4 mutations. The median time on therapy was 10.2 months, and the median time after the end of therapy (EOT) was 13.3 months. Eleven of the 12 progression events occurred after EOT, and the 12-month PFS rates after EOT were 79%; 93% if VGPR was attained, and 69% for other patients (P = .12). Ibrutinib and venetoclax induced high VGPR rates and durable responses after EOT, although they were associated with a higher-than-expected rate of ventricular arrhythmia in patients with WM, leading to early study treatment termination. This trial was registered at www.clinicaltrials.gov as #NCT04273139.
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Affiliation(s)
- Jorge J. Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Andrew R. Branagan
- Department of Medicine, Harvard Medical School, Boston, MA
- Center for Multiple Myeloma, Massachusetts General Hospital, Boston, MA
| | - David Sermer
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Catherine A. Flynn
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Kirsten Meid
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Megan Little
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Katherine Stockman
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Timothy White
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Alexa Canning
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Maria L. Guerrera
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Amanda Kofides
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Shirong Liu
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Xia Liu
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Kris Richardson
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Nicholas Tsakmaklis
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | | | - Zachary R. Hunter
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Steven P. Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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25
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Stumpf J, Al-Sawaf O. Chronic Lymphocytic Leukemia: Time-Limited Therapy in the First-Line Setting and Role of Minimal Residual Disease. Curr Oncol Rep 2024; 26:136-146. [PMID: 38175465 PMCID: PMC10891251 DOI: 10.1007/s11912-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW In this review, we provide an overview of different time-limited combination therapies of chronic lymphocytic leukemia (CLL) and summarize the data of pivotal clinical studies. Furthermore, we discuss the relevance of MRD in clinical trials and summarize the challenges that arise in routine clinical care. Finally, we provide an outlook on studies and datasets needed to optimize the use of time-limited treatment strategies and MRD assessments in modern CLL management. RECENT FINDINGS In recent years, first-line treatment of CLL has undergone a considerable transformation, with targeted substances having largely replaced chemoimmunotherapy (CIT) as a time-limited strategy in the frontline setting. BTK inhibitors were the first class of targeted agents introduced in CLL, which achieved longer progression-free survival (PFS) and in some cases also overall survival (OS) than CIT. However, this required an indefinite drug intake until disease progression, while CIT is generally administered over the course of few months. In contrast to BTK inhibitors, BCL2 inhibitors, another class of targeted agents, can achieve high rates of undetectable minimal residual disease (uMRD) levels and induce deep molecular remissions with the potential to stop treatment while maintaining remissions. Combinations of BCL2 inhibitors with CD20 antibodies or with BTK inhibitors have been explored to establish time-limited treatment strategies with targeted agents. In this context, one of the strongest predictors of long-term outcomes is MRD status at the end of treatment, which has been shown to correlate closely with PFS and OS in most cases.
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Affiliation(s)
- Janina Stumpf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cologne, Germany
- Cancer Institute, University College London, London, UK
- Francis Crick Institute, London, UK
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26
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Al-Sawaf O, Davids MS. Overcoming Resistance in Chronic Lymphocytic Leukemia-Maybe Less Is More? Clin Cancer Res 2024; 30:471-473. [PMID: 38055246 PMCID: PMC10841601 DOI: 10.1158/1078-0432.ccr-23-2872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
Acquired mutations in BTK, PLCG2, and BCL2 are associated with resistance to continuous targeted agent therapy in chronic lymphocytic leukemia (CLL). Here, we discuss new evidence that limiting the duration of CLL therapy may prevent the evolution of such resistance mutations, potentially facilitating effective retreatment strategies. See related article by Jain et al., p. 498.
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Affiliation(s)
- Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany
- Cancer Institute, University College London, United Kingdom
- Francis Crick Institute, London, United Kingdom
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, United States of America
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27
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Jain N, Croner LJ, Allan JN, Siddiqi T, Tedeschi A, Badoux XC, Eckert K, Cheung LW, Mukherjee A, Dean JP, Szafer-Glusman E, Seymour JF. Absence of BTK, BCL2, and PLCG2 Mutations in Chronic Lymphocytic Leukemia Relapsing after First-Line Treatment with Fixed-Duration Ibrutinib plus Venetoclax. Clin Cancer Res 2024; 30:498-505. [PMID: 37955424 PMCID: PMC10831330 DOI: 10.1158/1078-0432.ccr-22-3934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/27/2023] [Accepted: 08/14/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE Mutations in BTK, PLCG2, and BCL2 have been reported in patients with progressive disease (PD) on continuous single-agent BTK or BCL2 inhibitor treatment. We tested for these mutations in samples from patients with PD after completion of first-line treatment with fixed-duration ibrutinib plus venetoclax for chronic lymphocytic leukemia (CLL) in the phase II CAPTIVATE study. PATIENTS AND METHODS A total of 191 patients completed fixed-duration ibrutinib plus venetoclax (three cycles of ibrutinib then 12-13 cycles of ibrutinib plus venetoclax). Genomic risk features [del(11q), del(13q), del(17p), trisomy 12, complex karyotype, unmutated IGHV, TP53 mutated] and mutations in genes recurrently mutated in CLL (ATM, BIRC3, BRAF, CHD2, EZH2, FBXW7, MYD88, NOTCH1, POT1, RPS15, SF3B1, XPO1) were assessed at baseline in patients with and without PD at data cutoff; gene variants and resistance-associated mutations in BTK, PLCG2, or BCL2 were evaluated at PD. RESULTS Of 191 patients completing fixed-duration ibrutinib plus venetoclax, with median follow-up of 38.9 months, 29 (15%) developed PD. No baseline risk feature or gene mutation was significantly associated with development of PD. No previously reported resistance-associated mutations in BTK, PLCG2, or BCL2 were detected at PD in 25 patients with available samples. Of the 29 patients with PD, 19 have required retreatment (single-agent ibrutinib, n = 16, or ibrutinib plus venetoclax, n = 3); 17 achieved partial response or better, 1 achieved stable disease, and 1 is pending response assessment. CONCLUSIONS First-line fixed-duration combination treatment with ibrutinib plus venetoclax may mitigate development of resistance mechanisms associated with continuous single-agent targeted therapies, allowing for effective retreatment. See related commentary by Al-Sawaf and Davids, p. 471.
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Affiliation(s)
- Nitin Jain
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisa J. Croner
- AbbVie, North Chicago, Illinois
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | | | - Tanya Siddiqi
- City of Hope National Medical Center, Duarte, California
| | | | | | - Karl Eckert
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - Leo W.K. Cheung
- AbbVie, North Chicago, Illinois
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - Anwesha Mukherjee
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - James P. Dean
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - Edith Szafer-Glusman
- AbbVie, North Chicago, Illinois
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - John F. Seymour
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
- Royal Melbourne Hospital, and University of Melbourne, Melbourne, Victoria, Australia
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Goto H, Ito S, Kizaki M, Yamaguchi M, Fukuhara N, Kato K, Saito T, Terui Y, Okubo S, Soshin T, Zeng J, Honda H, Badawi M, Ross JA, Izutsu K. Phase 2 study of ibrutinib plus venetoclax in Japanese patients with relapsed/refractory mantle cell lymphoma. Int J Clin Oncol 2024; 29:232-240. [PMID: 38157190 PMCID: PMC10808627 DOI: 10.1007/s10147-023-02443-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/13/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Despite high response rates to initial therapy, most patients with mantle cell lymphoma (MCL) experience relapsed or refractory (R/R) disease. Here, we report the efficacy, safety, and pharmacokinetics of the Phase 2, single-arm M20-075 study (NCT04477486) of ibrutinib and venetoclax combination therapy in Japanese patients with R/R MCL. METHODS Patients received 560 mg ibrutinib and 400 mg venetoclax (after a 5-week ramp-up from 20 mg) once daily for up to 104 weeks. Primary endpoint was complete response (CR) rate by independent review committee (IRC). Secondary endpoints included overall response rate (ORR), duration of response (DOR), undetectable minimal residual disease (uMRD) rate, progression-free survival (PFS), overall survival (OS), safety including dose-limiting toxicity (DLT) assessment in the first six patients, and pharmacokinetic parameters. Full analysis set (FAS) comprised all treated patients. Per protocol set (PPS) excluded treated patients with non-evaluable disease at baseline by IRC. RESULTS Thirteen patients were treated (FAS n = 13; PPS, n = 12). Median age was 71 years, patients had a median of two prior treatments. After a median follow-up of 9.6 months, IRC-assessed CR rate and ORR were both 83% (PPS). All six MRD-evaluable patients had uMRD. Median DOR, PFS, and OS were unreached. The most common Grade ≥ 3 treatment-emergent adverse event (TEAE) was neutropenia (23%); 1 patient discontinued due to squamous cell carcinoma of the lung. No DLTs, tumor lysis syndrome, or deaths related to TEAEs were observed. CONCLUSION Ibrutinib plus venetoclax exhibited high response rates and a well-tolerated safety profile in Japanese patients with R/R MCL.
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Affiliation(s)
- Hideki Goto
- Department of Hematology, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-Ku, Sapporo-Shi, Hokkaido, Japan.
| | - Satoshi Ito
- Department of Neurology, Hematology, Metabolism, Endocrinology and Diabetology (3rd Department of Internal Medicine), Yamagata University Hospital, 2-2-2 Iida-Nishi, Yamagata-Shi, Yamagata, Japan
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe-Shi, Saitama, Japan
| | - Masaki Yamaguchi
- Department of Hematology, Ishikawa Prefectural Central Hospital, 2-1 Kuratsuki Higashi, Kanazawa-Shi, Ishikawa, Japan
| | - Noriko Fukuhara
- Department of Hematology, Tohoku University Hospital, 1-1 Seiryo-Machi, Aoba-Ku, Sendai-Shi, Miyagi, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, 3-1-1 Maidashi, Higashi-Ku, Fukuoka-Shi, Fukuoka, Japan
| | - Toko Saito
- Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-Ku, Nagoya-Shi, Aichi, Japan
| | - Yasuhito Terui
- Department of Hematology, Saitama Medical University Hospital, 38 Morohongo, Moroyama-Machi, Iruma-Gun, Saitama, Japan
| | - Sumiko Okubo
- Japan Development, AbbVie GK, 3-1-21Minato-Ku, Shibaura, Tokyo, Japan
| | - Tomomi Soshin
- Japan Development, AbbVie GK, 3-1-21Minato-Ku, Shibaura, Tokyo, Japan
| | - Jiewei Zeng
- Department of Data and Statistical Sciences, AbbVie, Inc., 1400 Sheridan Rd, North Chicago, IL, USA
| | - Hideyuki Honda
- Japan Development, AbbVie GK, 3-1-21Minato-Ku, Shibaura, Tokyo, Japan
| | - Mohamed Badawi
- Department of Clinical Pharmacology, AbbVie, Inc., 1400 Sheridan Rd, North Chicago, IL, USA
| | - Jeremy A Ross
- Department of Precision Medicine, AbbVie, Inc., 1400 Sheridan Rd, North Chicago, IL, USA
| | - Koji Izutsu
- Department of Hematology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, Japan
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Zygmunciak P, Robak T, Puła B. Treatment of Double-Refractory Chronic Lymphocytic Leukemia-An Unmet Clinical Need. Int J Mol Sci 2024; 25:1589. [PMID: 38338868 PMCID: PMC10855898 DOI: 10.3390/ijms25031589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Recent years have seen significant improvement in chronic lymphocytic leukemia (CLL) management. Targeting B-cell lymphoma (BCL-2) and Bruton's kinase (BTK) have become the main strategies to restrain CLL activity. These agents are generally well tolerated, but the discontinuation of these therapies happens due to resistance, adverse effects, and Richter's transformation. A growing population of patients who have previously used both BTK inhibitors and BCL2 suffer from the constriction of the following regimens. This review explores the resistance mechanisms for both ibrutinib and venetoclax. Moreover, we present innovative approaches evaluated for treating double-refractory CLL.
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Affiliation(s)
- Przemysław Zygmunciak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (P.Z.); (B.P.)
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
- Department of General Hematology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
| | - Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (P.Z.); (B.P.)
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30
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Munir T, Cairns DA, Bloor A, Allsup D, Cwynarski K, Pettitt A, Paneesha S, Fox CP, Eyre TA, Forconi F, Elmusharaf N, Kennedy B, Gribben J, Pemberton N, Sheehy O, Preston G, Schuh A, Walewska R, Duley L, Howard D, Hockaday A, Jackson S, Greatorex N, Girvan S, Bell S, Brown JM, Webster N, Dalal S, de Tute R, Rawstron A, Patten PEM, Hillmen P. Chronic Lymphocytic Leukemia Therapy Guided by Measurable Residual Disease. N Engl J Med 2024; 390:326-337. [PMID: 38078508 DOI: 10.1056/nejmoa2310063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The combination of ibrutinib and venetoclax has been shown to improve outcomes in patients with chronic lymphocytic leukemia (CLL) as compared with chemoimmunotherapy. Whether ibrutinib-venetoclax and personalization of treatment duration according to measurable residual disease (MRD) is more effective than fludarabine-cyclophosphamide-rituximab (FCR) is unclear. METHODS In this phase 3, multicenter, randomized, controlled, open-label platform trial involving patients with untreated CLL, we compared ibrutinib-venetoclax and ibrutinib monotherapy with FCR. In the ibrutinib-venetoclax group, after 2 months of ibrutinib, venetoclax was added for up to 6 years of therapy. The duration of ibrutinib-venetoclax therapy was defined by MRD assessed in peripheral blood and bone marrow and was double the time taken to achieve undetectable MRD. The primary end point was progression-free survival in the ibrutinib-venetoclax group as compared with the FCR group, results that are reported here. Key secondary end points were overall survival, response, MRD, and safety. RESULTS A total of 523 patients were randomly assigned to the ibrutinib-venetoclax group or the FCR group. At a median of 43.7 months, disease progression or death had occurred in 12 patients in the ibrutinib-venetoclax group and 75 patients in the FCR group (hazard ratio, 0.13; 95% confidence interval [CI], 0.07 to 0.24; P<0.001). Death occurred in 9 patients in the ibrutinib-venetoclax group and 25 patients in the FCR group (hazard ratio, 0.31; 95% CI, 0.15 to 0.67). At 3 years, 58.0% of the patients in the ibrutinib-venetoclax group had stopped therapy owing to undetectable MRD. After 5 years of ibrutinib-venetoclax therapy, 65.9% of the patients had undetectable MRD in the bone marrow and 92.7% had undetectable MRD in the peripheral blood. The risk of infection was similar in the ibrutinib-venetoclax group and the FCR group. The percentage of patients with cardiac serious adverse events was higher in the ibrutinib-venetoclax group than in the FCR group (10.7% vs. 0.4%). CONCLUSIONS MRD-directed ibrutinib-venetoclax improved progression-free survival as compared with FCR, and results for overall survival also favored ibrutinib-venetoclax. (Funded by Cancer Research UK and others; FLAIR ISRCTN Registry number, ISRCTN01844152; EudraCT number, 2013-001944-76.).
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Affiliation(s)
- Talha Munir
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - David A Cairns
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Adrian Bloor
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - David Allsup
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Kate Cwynarski
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Andrew Pettitt
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Shankara Paneesha
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Christopher P Fox
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Toby A Eyre
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Francesco Forconi
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nagah Elmusharaf
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Ben Kennedy
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - John Gribben
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nicholas Pemberton
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Oonagh Sheehy
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Gavin Preston
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Anna Schuh
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Renata Walewska
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Lelia Duley
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Dena Howard
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Anna Hockaday
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sharon Jackson
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Natasha Greatorex
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sean Girvan
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Sue Bell
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Julia M Brown
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Nichola Webster
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Surita Dalal
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Ruth de Tute
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Andrew Rawstron
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Piers E M Patten
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
| | - Peter Hillmen
- From the Department of Clinical Hematology (T.M., P.H.) and the Hematological Malignancy Diagnostic Service (N.W., S.D., R.T., A.R.), Leeds Cancer Centre, and the Leeds Cancer Research UK Clinical Trials Unit (D.A.C., D.H., A.H., S.J., N.G., S.G., S.B., J.M.B.) and Leeds Institute of Medical Research (N.W., S.D., P.H.), University of Leeds, Leeds, the Christie Hospital NHS Foundation Trust and the University of Manchester, Manchester (A.B.), Hull University Teaching Hospitals NHS Trust, Hull (D.A.), University College London Hospitals NHS Foundation Trust (K.C.), the Comprehensive Cancer Centre, King's College London (P.E.M.P.), King's College Hospital NHS Foundation Trust (P.E.M.P.), and Barts Health NHS Trust (J.G.), London, the Clatterbridge Cancer Centre NHS Foundation Trust and the University of Liverpool, Liverpool (A.P.), University Hospitals Birmingham NHS Foundation Trust, Birmingham (S.P.), Nottingham University Hospitals NHS Trust, Nottingham (C.P.F), Oxford University Hospitals NHS Foundation Trust, Oxford (T.A.E., A.S.), Cancer Sciences, Faculty of Medicine, University of Southampton and the Hematology Department, Cancer Care Directorate, University Hospital Southampton NHS Foundation Trust, Southampton (F.F.), University Hospital of Wales, Cardiff (N.E.), University Hospitals of Leicester NHS Trust, Leicester (B.K.), Worcestershire Acute Hospitals NHS Trust, Worcester (N.P.), Belfast City Hospital, Belfast (O.S.), Aberdeen Royal Infirmary, Aberdeen (G.P.), University Hospitals Dorset NHS Foundation Trust, Bournemouth (R.W.), and CLL Support, Chippenham (L.D.) - all in the United Kingdom
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31
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Woyach JA, Stephens DM, Flinn IW, Bhat SA, Savage RE, Chai F, Eathiraj S, Reiff SD, Muhowski EM, Granlund L, Szuszkiewicz L, Wang W, Schwartz B, Ghori R, Farooqui MZH, Byrd JC. First-in-Human Study of the Reversible BTK Inhibitor Nemtabrutinib in Patients with Relapsed/Refractory Chronic Lymphocytic Leukemia and B-Cell Non-Hodgkin Lymphoma. Cancer Discov 2024; 14:66-75. [PMID: 37930156 DOI: 10.1158/2159-8290.cd-23-0670] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
Nemtabrutinib is an orally bioavailable, reversible inhibitor of Bruton tyrosine kinase (BTK) and C481S mutant BTK. We evaluated the safety, pharmacology, and antitumor activity of nemtabrutinib in relapsed/refractory hematologic malignancies. Forty-eight patients with chronic lymphocytic leukemia (CLL), B-cell non-Hodgkin lymphoma (NHL), or Waldenström macroglobulinemia (WM), relapsed/refractory after ≥2 prior therapies were enrolled in the open-label, single-arm, phase I MK-1026-001 study (NCT03162536) to receive nemtabrutinib 5 to 75 mg once daily in 28-day cycles. Dose finding progressed using a 3 + 3 dose escalation design. Primary endpoints were safety and the recommended phase II dose (RP2D). Among 47 treated patients, 29 had CLL, 17 had NHL, and 1 had WM. Grade ≥3 treatment-emergent adverse events occurred in 37 (89%), most commonly neutropenia (11; 23.4%), febrile neutropenia (7; 14.9%), and pneumonia (7; 14.9%). The RP2D was 65 mg daily. An overall response rate of 75% was observed in patients with CLL at 65 mg daily. SIGNIFICANCE This first-in-human phase I study demonstrates the safety and preliminary efficacy of nemtabrutinib in patients with relapsed/refractory B-cell malignancies. These data support further exploration of nemtabrutinib in larger clinical studies. This article is featured in Selected Articles from This Issue, p. 5.
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Affiliation(s)
| | | | - Ian W Flinn
- Sarah Cannon Research Institute, Nashville, Tennessee
| | | | | | | | | | | | | | | | | | - Wayne Wang
- Veristat, LLC, Southborough, Massachusetts
| | | | | | | | - John C Byrd
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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32
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Molica S, Tam C, Allsup D, Polliack A. Targeting TP53 disruption in chronic lymphocytic leukemia: Current strategies and future directions. Hematol Oncol 2024; 42:e3238. [PMID: 37937506 DOI: 10.1002/hon.3238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/14/2023] [Accepted: 10/19/2023] [Indexed: 11/09/2023]
Abstract
In the modern era of Chronic Lymphocytic Leukemia (CLL) targeted therapy, the loss of p53 function due to genetic abnormalities remains a significant challenge. This is because even targeted agents, which are currently the mainstay of treatment for CLL, do not directly target p53 or restore its disrupted pathway. Consequently, resistance to therapy and unfavorable clinical outcomes often accompany these p53-related abnormalities. An essential goal of future clinical research should be to address the ostensibly "undruggable" p53 pathway. Currently, multiple therapeutic approaches are being explored to tackle TP53 dysfunction and improve outcomes in high-risk CLL. These approaches include the use of oncoprotein murine double minute 2 inhibitors, small-molecule p53 reactivators, exportin 1 (XPO1) inhibitors, and ataxia-telangiectasia mutated and Rad3-related (ATR) inhibitors. Combinations of these p53-targeting strategies, along with established novel therapies such as B-cell receptor or B-cell lymphoma-2 (BCL-2) inhibitors, may shape the future of therapeutic trials in this challenging-to-treat disease.
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Affiliation(s)
- Stefano Molica
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
| | | | - David Allsup
- Centre of Biomedicine, Hull York Medical School, University of Hull, Hull, UK
| | - Aaron Polliack
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Sánchez Suárez MDM, Martín Roldán A, Alarcón-Payer C, Rodríguez-Gil MÁ, Poquet-Jornet JE, Puerta Puerta JM, Jiménez Morales A. Treatment of Chronic Lymphocytic Leukemia in the Personalized Medicine Era. Pharmaceutics 2023; 16:55. [PMID: 38258066 PMCID: PMC10818903 DOI: 10.3390/pharmaceutics16010055] [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: 10/16/2023] [Revised: 11/26/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic lymphocytic leukemia is a lymphoproliferative disorder marked by the expansion of monoclonal, mature CD5+CD23+ B cells in peripheral blood, secondary lymphoid tissues, and bone marrow. The disease exhibits significant heterogeneity, with numerous somatic genetic alterations identified in the neoplastic clone, notably mutated TP53 and immunoglobulin heavy chain mutational statuses. Recent studies emphasize the pivotal roles of genetics and patient fragility in treatment decisions. This complexity underscores the need for a personalized approach, tailoring interventions to individual genetic profiles for heightened efficacy. The era of personalized treatment in CLL signifies a transformative shift, holding the potential for improved outcomes in the conquest of this intricate hematologic disorder. This review plays a role in elucidating the evolving CLL treatment landscape, encompassing all reported genetic factors. Through a comprehensive historical analysis, it provides insights into the evolution of CLL management. Beyond its retrospective nature, this review could be a valuable resource for clinicians, researchers, and stakeholders, offering a window into the latest advancements. In essence, it serves as a dynamic exploration of our current position and the promising prospects on the horizon.
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Affiliation(s)
- María Del Mar Sánchez Suárez
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Alicia Martín Roldán
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Carolina Alarcón-Payer
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Miguel Ángel Rodríguez-Gil
- Unidad de Gestión Clínica Hematología y Hemoterapia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.Á.R.-G.); (J.M.P.P.)
| | | | - José Manuel Puerta Puerta
- Unidad de Gestión Clínica Hematología y Hemoterapia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.Á.R.-G.); (J.M.P.P.)
| | - Alberto Jiménez Morales
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
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34
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Rhodes JM. MRD-directed therapy in CLL: ready for prime time? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:413-420. [PMID: 38066928 PMCID: PMC10727082 DOI: 10.1182/hematology.2023000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
In recent years, the treatment paradigm for patients with chronic lymphocytic leukemia (CLL) has moved away from chemoimmunotherapy (CIT) toward the use of novel targeted agents. Commercially available drugs, including Bruton's tyrosine kinase inhibitors and the BCL2 inhibitor venetoclax, often used in combination with anti-CD20 monoclonal antibodies, are now the mainstay of therapy both in the frontline and in relapsed settings. As the landscape for CLL management evolves, therapeutic endpoints need to be redefined. Detection of measurable residual disease (MRD) is a sensitive tool to identify disease burden following treatment with several therapeutic regimens in CLL (including CIT, venetoclax-based regimens, and cellular therapies), and it has demonstrated prognostic value. Despite recent advances, the utility of MRD-directed therapy and attempts to eradicate it in routine clinical practice remain debated. There is little comparative data from clinical trials on the best assay to determine undetectable MRD (U-MRD) and whether its monitoring can lead to changes in treatment strategies. Our review discusses the definitions of MRD, assays for its detection, and its impact on long-term survival outcomes for patients with a CLL diagnosis.
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Affiliation(s)
- Joanna M. Rhodes
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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35
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Ujjani C. Dual-targeted regimens for the frontline treatment of CLL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:421-426. [PMID: 38066921 PMCID: PMC10726988 DOI: 10.1182/hematology.2023000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The treatment landscape of chronic lymphocytic leukemia (CLL) has evolved considerably over the past decade due to the development of effective novel agents with varying mechanisms of action, including Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL2) inhibitors. Extrapolating upon the success of anti-CD20-directed chemoimmunotherapy, a dual-targeted approach has been explored in treatment-naive patients with CLL. Anti-CD20 monoclonal antibody combinations with BTK inhibitors as well as BCL2 inhibitors have demonstrated superiority over traditional cytotoxic chemoimmunotherapy regimens such as fludarabine, cyclophosphamide, and rituximab; bendamustine-rituximab; and obinutuzumab-chlorambucil. Impressive clinical benefit is seen in both younger and older patients, those with comorbidities, and, most importantly, those with poor prognostic features. Given this success, combinations of BTK inhibitors and venetoclax have been explored in clinical trials. These dual-targeted regimens provide remarkable efficacy while allowing for an all-oral approach and fixed duration of treatment. Current investigations under way are evaluating the utility of a triplet approach with the addition of obinutuzumab in comparison to a doublet approach.
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Affiliation(s)
- Chaitra Ujjani
- Fred Hutchinson Cancer Center, University of Washington, Division of Medical Oncology, Seattle, WA
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36
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Del Giudice I, Foà R. Measurable residual disease in chronic lymphocytic leukemia. Where do we stand? Leukemia 2023; 37:2339-2342. [PMID: 37838758 DOI: 10.1038/s41375-023-02066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023]
Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
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37
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Niemann CU, Munir T, Moreno C, Owen C, Follows GA, Benjamini O, Janssens A, Levin MD, Robak T, Simkovic M, Voloshin S, Vorobyev V, Yagci M, Ysebaert L, Qi K, Qi Q, Sinet P, Parisi L, Srinivasan S, Schuier N, Baeten K, Howes A, Caces DB, Kater AP. Fixed-duration ibrutinib-venetoclax versus chlorambucil-obinutuzumab in previously untreated chronic lymphocytic leukaemia (GLOW): 4-year follow-up from a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 2023; 24:1423-1433. [PMID: 37944541 DOI: 10.1016/s1470-2045(23)00452-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In the GLOW study, fixed-duration ibrutinib-venetoclax showed superior progression-free survival versus chlorambucil-obinutuzumab in patients with previously untreated chronic lymphocytic leukaemia who were older or had comorbidities, or both, at a median follow up of 27·7 months. In this Article, we report updated outcomes from GLOW after a 46-month median follow-up. METHODS GLOW was a randomised, multicentre, phase 3 study done at 67 hospital centres across 14 countries. Patients aged 65 years and older or 18-64 years with previously untreated chronic lymphocytic leukaemia and a cumulative illness rating scale score of more than 6 or creatinine clearance less than 70 mL/min, or both, and an Eastern Cooperative Oncology Group performance status of 2 or less were randomly assigned (1:1) via an interactive web system with permuted blocks (block size of four) and stratified by IGHV mutational status and the presence of del11q aberration to the ibrutinib-venetoclax group (three cycles of ibrutinib lead-in [420 mg/day, orally], followed by 12 cycles of ibrutinib plus venetoclax [400 mg/day, orally, including a 5-week dose ramp-up]) or the chlorambucil-obinutuzumab group (six cycles of chlorambucil [0·5 mg/kg, orally, on days 1 and 15 of each cycle], and obinutuzumab [1000 mg, intravenously, on days 1 (or 100 mg on day 1 and 900 mg on day 2), 8, and 15 of cycle 1 and day 1 of cycles 2-6]). The primary endpoint was progression-free survival in the intention-to-treat population, assessed by an independent review committee. The safety population included all randomised patients who received at least one dose of the study treatment. This study is registered with ClinicalTrials.gov (NCT03462719) and the EU Clinical Trials Register (EudraCT 2017-004699-77). FINDINGS Between May 4, 2018, and April 5, 2019, 211 patients (122 [58%] were male and 89 [42%] were female) were randomly assigned to receive ibrutinib-venetoclax (n=106) or chlorambucil-obinutuzumab (n=105). At a median of 46 months (IQR 43-47) of follow-up, progression-free survival remained superior for the ibrutinib-venetoclax group (hazard ratio 0·214 [95% CI 0·138-0·334]; p<0·0001); 42-month progression-free survival rates were 74·6% (95% CI 65·0-82·0) for ibrutinib-venetoclax and 24·8% (16·5-34·1) for chlorambucil-obinutuzumab. Following the primary analysis, one patient in the chlorambucil-obinutuzumab group had a serious adverse event of myelodysplastic syndrome. Treatment-related deaths were reported in one patient receiving ibrutinib-venetoclax (cardiac failure, pneumonia, and sinus node dysfunction) and in one patient receiving chlorambucil-obinutuzumab (pneumonia). There were 15 deaths in the ibrutinib-venetoclax group (of which three were due to post-treatment infections) and 30 deaths in the chlorambucil-obinutuzumab group (of which 10 were due to post-treatment infections). INTERPRETATION After 4 years of follow-up, ibrutinib-venetoclax continues to significantly prolong progression-free survival (vs chemoimmunotherapy) in patients with previously untreated chronic lymphocytic leukaemia, supporting its use as a first-line option. FUNDING Janssen Research & Development and Pharmacyclics.
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Affiliation(s)
- Carsten U Niemann
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | | | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | | | | | | | | | | | - Tadeusz Robak
- Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland
| | - Martin Simkovic
- 4th Department of Internal Medicine-Haematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Hradec Králové, Czech Republic
| | - Sergey Voloshin
- Russian Scientific and Research Institute of Hematology and Transfusiology, St Petersburg, Russia
| | | | - Munci Yagci
- Gazi Universitesi Tip Fakultesi, Ankara, Türkiye
| | - Loic Ysebaert
- Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
| | - Keqin Qi
- Janssen Research & Development, Titusville, NJ, USA
| | - Qianya Qi
- Janssen Research & Development, Raritan, NJ, USA
| | - Pierre Sinet
- Janssen Research & Development, Bridgewater, NJ, USA
| | - Lori Parisi
- Janssen Research & Development, Raritan, NJ, USA
| | - Srimathi Srinivasan
- Oncology Translational Research, Janssen Research & Development, Lower Gwynedd Township, PA, USA
| | | | - Kurt Baeten
- Janssen Research & Development, Beerse, Belgium
| | - Angela Howes
- Janssen Research & Development, High Wycombe, UK
| | | | - Arnon P Kater
- Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, Netherlands
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Baratè C, Sanna A, Benedetti E, Bocchia M, Capochiani E, Danesi R, Moretti S, Occhini U, Santini S, Galimberti S, Gozzetti A. Real-life diagnostic and therapeutic approach to CLL: a 2022 update from an expert panel in Tuscany. Clin Exp Med 2023; 23:4251-4264. [PMID: 37979127 DOI: 10.1007/s10238-023-01244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
A panel of chronic lymphocytic leukemia (CLL) experts from Tuscany propose a real-life diagnostic and therapeutic approach CLL that considers the role of genomic and somatic prognostic factors in risk stratification and treatment decisions. Safety and efficacy of new agents has been demonstrated now not only in clinical trials but also in many real-world series. The BTK inhibitors, ibrutinib and acalabrutinib, and BH3 mimetic venetoclax are now indicated as first-line therapy and chemoimmunotherapy can be spared to the majority of CLL patients, thus preventing unnecessary hematological and non-hematological toxicity and second primary tumors. For treatment, FISH for 17 p and P53 mutational status are essential. IGHV mutation can be done at diagnosis or before treatment. Echography is the gold standard radiological investigation in CLL, at both diagnosis and response evaluation. Chemotherapy is virtually abandoned. Age, genetic risk, and patient comorbidities have to be carefully evaluated for treatment decision. With the availability of different drugs, there is a need for a uniform and shared approach in daily therapeutic choice. The proposed approach is based on current evidence and guidelines as well as results from clinical trials and daily clinical experience.
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Affiliation(s)
- Claudia Baratè
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Edoardo Benedetti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), Pisa, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Enrico Capochiani
- Hematology Unit, Department of Internal Medicine, Toscana Nord Ovest, Leghorn, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | | | | | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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Cuzzo B, Lipsky A, Cherng HJJ. Measurable Residual Disease Monitoring in Lymphoma. Curr Hematol Malig Rep 2023; 18:292-304. [PMID: 37930608 DOI: 10.1007/s11899-023-00715-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE OF REVIEW The utility of analyzing circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and disease in the bone marrow as an adjunctive tool in caring for hematologic cancer patients is expanding. This holds true for lymphoma where these biomarkers are being explored as a means of genotyping and quantifying disease. Regarding the latter, they can be used to monitor measurable residual disease (MRD) during and after treatment. This holds potential for aiding clinical decisions amidst treatment, detecting earlier relapse, and improving prognostication. Here, we review the evidence to support these applications in a variety of lymphoma subtypes. RECENT FINDINGS Numerous clinical trials across a variety of lymphomas have demonstrated value in MRD monitoring. MRD monitoring is often prognostic for progression free survival (PFS) and even overall survival (OS) at several time points in a disease course, particularly when utilizing serial measurements. With regards to tailoring treatment, there are a growing number of trials examining MRD-adaptive treatment strategies to intensify or de-escalate treatment to individualize care. Lastly, MRD monitoring has been utilized successfully in detecting earlier relapse when compared to more standard methods of clinical surveillance such as radiographic assessment. Although not routinely implemented into clinical practice, MRD monitoring in lymphoma is helping shape the future landscape of this disease by aiding in prognostication, guiding therapy, and detecting earlier relapse. Steps to standardize and further examine this technology prospectively are being taken to bring MRD monitoring to the forefront of the field.
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Affiliation(s)
- Brian Cuzzo
- Columbia University Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA
| | - Andrew Lipsky
- Columbia University Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA
| | - Hua-Jay J Cherng
- Columbia University Medical Center, 161 Fort Washington Ave, New York, NY, 10032, USA.
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Qiu TL, Miao Y, Li JY. [Advances in clinical research on novel BTK inhibitors for the treatment of chronic lymphocytic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:963-968. [PMID: 38185530 PMCID: PMC10753254 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Indexed: 01/09/2024]
Affiliation(s)
- T L Qiu
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - Y Miao
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - J Y Li
- Department of Hematology, Key Laboratory of Nanjing Medical University, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
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Cao Q, Wu X, Zhang Q, Gong J, Chen Y, You Y, Shen J, Qiang Y, Cao G. Mechanisms of action of the BCL-2 inhibitor venetoclax in multiple myeloma: a literature review. Front Pharmacol 2023; 14:1291920. [PMID: 38026941 PMCID: PMC10657905 DOI: 10.3389/fphar.2023.1291920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Abnormal cellular apoptosis plays a pivotal role in the pathogenesis of Multiple Myeloma (MM). Over the years, BCL-2, a crucial anti-apoptotic protein, has garnered significant attention in MM therapeutic research. Venetoclax (VTC), a small-molecule targeted agent, effectively inhibits BCL-2, promoting the programmed death of cancerous cells. While VTC has been employed to treat various hematological malignancies, its particular efficacy in MM has showcased its potential for broader clinical applications. In this review, we delve into the intricacies of how VTC modulates apoptosis in MM cells by targeting BCL-2 and the overarching influence of the BCL-2 protein family in MM apoptosis regulation. Our findings highlight the nuanced interplay between VTC, BCL-2, and MM, offering insights that may pave the way for optimizing therapeutic strategies. Through this comprehensive analysis, we aim to lay a solid groundwork for future explorations into VTC's clinical applications and the profound effects of BCL-2 on cellular apoptosis.
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Affiliation(s)
- Qiang Cao
- Department of Earth Sciences, Kunming University of Science and Technology, Kunming, China
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xinyan Wu
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, China
| | - Qi Zhang
- Undergraduate Department, Taishan University, Taian, China
| | - Junling Gong
- School of Public Health, Nanchang University, Nanchang, China
| | - Yuquan Chen
- Institute of Medical Information/Library, Chinese Academy of Medical Sciences, Beijing, China
| | - Yanwei You
- Division of Sports Science & Physical Education, Tsinghua University, Beijing, China
| | - Jun Shen
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Qiang
- Department of Earth Sciences, Kunming University of Science and Technology, Kunming, China
| | - Guangzhu Cao
- Department of Earth Sciences, Kunming University of Science and Technology, Kunming, China
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Perissinotti AJ, Bishop MR, Bubalo J, Geyer MB, Goodrich A, Howard SC, Kula J, Mandayam S, Cairo MS, Pui CH. Expert consensus guidelines for the prophylaxis and management of tumor lysis syndrome in the United States: Results of a modified Delphi panel. Cancer Treat Rev 2023; 120:102603. [PMID: 37579533 DOI: 10.1016/j.ctrv.2023.102603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Tumor lysis syndrome (TLS), which occurs spontaneously or in response to anticancer treatment, results in the release of intracellular potassium, phosphorus, and nucleic acids into the bloodstream, which results in secondary clinical complications that may be fatal. Prior TLS guidelines do not take into consideration potent novel oncologic agents or contemporary treatment paradigms with increased risk of TLS. Thus, a modified Delphi panel of experts was convened to provide an update for TLS management guidelines based upon a combination of supporting literature and practice consensus. METHODS A three-round modified Delphi process was implemented. For round 1, nine expert panelists completed a web-based questionnaire developed using published literature. In round 2, panelists were asked to reconsider their answers to questions that did not reach consensus (defined as ≥ 66% agreement among voting panelists). Round 3 was an unblinded, moderated virtual meeting to discuss any remaining questions that did not reach consensus. RESULTS Detailed recommendations are given for prophylaxis, monitoring, and management of TLS risks and complications, with hydration being a key element of TLS prophylaxis and management. Guidelines for the management of acute effects of TLS and prevention of long-term renal effects include management of hyperkalemia, hypocalcemia, hyperphosphatemia, and hyperuricemia. DISCUSSION Although the control of uric acid levels is quite effective with currently available agents, panelists emphasize the importance of monitoring and treating other dangerous electrolyte abnormalities such as hyperkalemia and hyperphosphatemia. Guidelines from this modified Delphi panel should aid clinicians in preventing and managing TLS.
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Affiliation(s)
- Anthony J Perissinotti
- University of Michigan Health - Michigan Medicine, Department of Pharmacy, Ann Arbor, MI 48109, USA
| | - Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Joseph Bubalo
- Department of Pharmacy/Division of Hematology and Medical Oncology, OHSU Hospital and Clinics, Pharmacy Services, Portland, OR 97239, USA
| | - Mark B Geyer
- Leukemia and Cell Therapy Services, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
| | - Amy Goodrich
- Johns Hopkins Kimmel Cancer Center, Baltimore, MD 21231, USA
| | - Scott C Howard
- University of Tennessee Health Sciences Center, Memphis, TN 38103, USA
| | - Julianna Kula
- Rocky Mountain Cancer Centers, Greenwood Village, CO 80112, USA
| | - Sreedhar Mandayam
- Department of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mitchell S Cairo
- Department of Pediatrics, Cancer and Blood Diseases Center, New York Medical College, Valhalla, NY 10595, USA.
| | - Ching-Hon Pui
- Departments of Oncology, Global Pediatric Medicine, and Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Eide CA, Kurtz SE, Kaempf A, Long N, Joshi SK, Nechiporuk T, Huang A, Dibb CA, Taylor A, Bottomly D, McWeeney SK, Minnier J, Lachowiez CA, Saultz JN, Swords RT, Agarwal A, Chang BH, Druker BJ, Tyner JW. Clinical Correlates of Venetoclax-Based Combination Sensitivities to Augment Acute Myeloid Leukemia Therapy. Blood Cancer Discov 2023; 4:452-467. [PMID: 37698624 PMCID: PMC10618724 DOI: 10.1158/2643-3230.bcd-23-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/17/2023] [Accepted: 09/06/2023] [Indexed: 09/13/2023] Open
Abstract
The BCL2 inhibitor venetoclax combined with the hypomethylating agent azacytidine shows significant clinical benefit in a subset of patients with acute myeloid leukemia (AML); however, resistance limits response and durability. We prospectively profiled the ex vivo activity of 25 venetoclax-inclusive combinations on primary AML patient samples to identify those with improved potency and synergy compared with venetoclax + azacytidine (Ven + azacytidine). Combination sensitivities correlated with tumor cell state to discern three patterns: primitive selectivity resembling Ven + azacytidine, monocytic selectivity, and broad efficacy independent of cell state. Incorporation of immunophenotype, mutation, and cytogenetic features further stratified combination sensitivity for distinct patient subtypes. We dissect the biology underlying the broad, cell state-independent efficacy for the combination of venetoclax plus the JAK1/2 inhibitor ruxolitinib. Together, these findings support opportunities for expanding the impact of venetoclax-based drug combinations in AML by leveraging clinical and molecular biomarkers associated with ex vivo responses. SIGNIFICANCE By mapping drug sensitivity data to clinical features and tumor cell state, we identify novel venetoclax combinations targeting patient subtypes who lack sensitivity to Ven + azacytidine. This provides a framework for a taxonomy of AML informed by readily available sets of clinical and genetic features obtained as part of standard care. See related commentary by Becker, p. 437 . This article is featured in Selected Articles from This Issue, p. 419.
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Affiliation(s)
- Christopher A. Eide
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Stephen E. Kurtz
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Andy Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Nicola Long
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Sunil Kumar Joshi
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Tamilla Nechiporuk
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ariane Huang
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Charles A. Dibb
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Akosha Taylor
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Daniel Bottomly
- Division of Bioinformatics and Computational Biomedicine, Department of Medical Informatics and Clinical Epidemiology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Shannon K. McWeeney
- Division of Bioinformatics and Computational Biomedicine, Department of Medical Informatics and Clinical Epidemiology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jessica Minnier
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Curtis A. Lachowiez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jennifer N. Saultz
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Ronan T. Swords
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Anupriya Agarwal
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Bill H. Chang
- Division of Pediatric Hematology and Oncology, Knight Cancer Institute, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon
| | - Brian J. Druker
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Division of Oncological Sciences, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey W. Tyner
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Cell, Developmental, and Cancer Biology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
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Yuda J, Will C, Phillips DC, Abraham L, Alvey C, Avigdor A, Buck W, Besenhofer L, Boghaert E, Cheng D, Cojocari D, Doyle K, Hansen TM, Huang K, Johnson EF, Judd AS, Judge RA, Kalvass JC, Kunzer A, Lam LT, Li R, Martin RL, Mastracchio A, Mitten M, Petrich A, Wang J, Ward JE, Zhang H, Wang X, Wolff JE, Bell-McGuinn KM, Souers AJ. Selective MCL-1 inhibitor ABBV-467 is efficacious in tumor models but is associated with cardiac troponin increases in patients. COMMUNICATIONS MEDICINE 2023; 3:154. [PMID: 37880389 PMCID: PMC10600239 DOI: 10.1038/s43856-023-00380-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND MCL-1 is a prosurvival B-cell lymphoma 2 family protein that plays a critical role in tumor maintenance and survival and can act as a resistance factor to multiple anticancer therapies. Herein, we describe the generation and characterization of the highly potent and selective MCL-1 inhibitor ABBV-467 and present findings from a first-in-human trial that included patients with relapsed/refractory multiple myeloma (NCT04178902). METHODS Binding of ABBV-467 to human MCL-1 was assessed in multiple cell lines. The ability of ABBV-467 to induce tumor growth inhibition was investigated in xenograft models of human multiple myeloma and acute myelogenous leukemia. The first-in-human study was a multicenter, open-label, dose-escalation study assessing safety, pharmacokinetics, and efficacy of ABBV-467 monotherapy. RESULTS Here we show that administration of ABBV-467 to MCL-1-dependent tumor cell lines triggers rapid and mechanism-based apoptosis. In vivo, intermittent dosing of ABBV-467 as monotherapy or in combination with venetoclax inhibits the growth of xenografts from human hematologic cancers. Results from a clinical trial evaluating ABBV-467 in patients with multiple myeloma based on these preclinical data indicate that treatment with ABBV-467 can result in disease control (seen in 1 patient), but may also cause increases in cardiac troponin levels in the plasma in some patients (seen in 4 of 8 patients), without other corresponding cardiac findings. CONCLUSIONS The selectivity of ABBV-467 suggests that treatment-induced troponin release is a consequence of MCL-1 inhibition and therefore may represent a class effect of MCL-1 inhibitors in human patients.
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Affiliation(s)
| | | | | | | | | | - Abraham Avigdor
- Institute of Hematology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Erwin Boghaert
- AbbVie Inc, North Chicago, IL, USA
- , Pleasant Prairie, WI, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mike Mitten
- AbbVie Inc, North Chicago, IL, USA
- , Beach Park, IL, USA
| | - Adam Petrich
- AbbVie Inc, North Chicago, IL, USA
- Northwestern University, Chicago, IL, USA
- Daiichi Sankyo, Basking Ridge, NJ, USA
| | - Jin Wang
- AbbVie Inc, North Chicago, IL, USA
| | - James E Ward
- AbbVie Inc, North Chicago, IL, USA
- Seagen Inc., Bothell, WA, USA
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Xu J, Dong X, Huang DCS, Xu P, Zhao Q, Chen B. Current Advances and Future Strategies for BCL-2 Inhibitors: Potent Weapons against Cancers. Cancers (Basel) 2023; 15:4957. [PMID: 37894324 PMCID: PMC10605442 DOI: 10.3390/cancers15204957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/02/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Targeting the intrinsic apoptotic pathway regulated by B-cell lymphoma-2 (BCL-2) antiapoptotic proteins can overcome the evasion of apoptosis in cancer cells. BCL-2 inhibitors have evolved into an important means of treating cancers by inducing tumor cell apoptosis. As the most extensively investigated BCL-2 inhibitor, venetoclax is highly selective for BCL-2 and can effectively inhibit tumor survival. Its emergence and development have significantly influenced the therapeutic landscape of hematological malignancies, especially in chronic lymphocytic leukemia and acute myeloid leukemia, in which it has been clearly incorporated into the recommended treatment regimens. In addition, the considerable efficacy of venetoclax in combination with other agents has been demonstrated in relapsed and refractory multiple myeloma and certain lymphomas. Although venetoclax plays a prominent antitumor role in preclinical experiments and clinical trials, large individual differences in treatment outcomes have been characterized in real-world patient populations, and reduced drug sensitivity will lead to disease recurrence or progression. The therapeutic efficacy may vary widely in patients with different molecular characteristics, and key genetic mutations potentially result in differential sensitivities to venetoclax. The identification and validation of more novel biomarkers are required to accurately predict the effectiveness of BCL-2 inhibition therapy. Furthermore, we summarize the recent research progress relating to the use of BCL-2 inhibitors in solid tumor treatment and demonstrate that a wealth of preclinical models have shown promising results through combination therapies. The applications of venetoclax in solid tumors warrant further clinical investigation to define its prospects.
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Affiliation(s)
- Jiaxuan Xu
- Department of Hematology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, China-Australia Institute of Translational Medicine, School of Life Sciences, Nanjing University, Nanjing 210008, China; (J.X.); (X.D.); (P.X.)
| | - Xiaoqing Dong
- Department of Hematology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, China-Australia Institute of Translational Medicine, School of Life Sciences, Nanjing University, Nanjing 210008, China; (J.X.); (X.D.); (P.X.)
| | - David C. S. Huang
- Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC 3052, Australia;
- Department of Medical Biology, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Peipei Xu
- Department of Hematology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, China-Australia Institute of Translational Medicine, School of Life Sciences, Nanjing University, Nanjing 210008, China; (J.X.); (X.D.); (P.X.)
| | - Quan Zhao
- Department of Hematology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, China-Australia Institute of Translational Medicine, School of Life Sciences, Nanjing University, Nanjing 210008, China; (J.X.); (X.D.); (P.X.)
| | - Bing Chen
- Department of Hematology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, China-Australia Institute of Translational Medicine, School of Life Sciences, Nanjing University, Nanjing 210008, China; (J.X.); (X.D.); (P.X.)
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46
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Audil HY, Kosydar SR, Larson DP, Parikh SA. Richter Transformation of Chronic Lymphocytic Leukemia-Are We Making Progress? Curr Hematol Malig Rep 2023; 18:144-157. [PMID: 37294394 DOI: 10.1007/s11899-023-00701-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The treatment paradigm of chronic lymphocytic leukemia (CLL) has dramatically changed with the advent of novel targeted agents over the past decade. Richter transformation (RT), or the development of an aggressive lymphoma from a background of CLL, is a well-recognized complication of CLL and carries significantly poor clinical outcomes. Here, we provide an update on current diagnostics, prognostication, and contemporary treatment of RT. RECENT FINDINGS Several genetic, biologic, and laboratory markers have been proposed as candidate risk factors for the development of RT. Although a diagnosis of RT is typically suspected based on clinical and laboratory findings, tissue biopsy is essential for histopathologic confirmation of diagnosis. The standard of care for RT treatment at this time remains chemoimmunotherapy with the goal of proceeding to allogeneic stem cell transplantation in eligible patients. Several newer treatment modalities are being studied for use in the management of RT, including small molecules, immunotherapy, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T) therapy. The management of patients with RT remains a challenge. Ongoing trials show enormous promise for newer classes of therapy in RT, with the hope being that these agents can synergize, and perhaps supersede, the current standard of care in the near future.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Immunotherapy
- Biopsy
- Cell Transformation, Neoplastic/genetics
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Affiliation(s)
- Hadiyah Y Audil
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel R Kosydar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel P Larson
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Sameer A Parikh
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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47
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Moreno C, Solman IG, Tam CS, Grigg A, Scarfò L, Kipps TJ, Srinivasan S, Mali RS, Zhou C, Dean JP, Szafer-Glusman E, Choi M. Immune restoration with ibrutinib plus venetoclax in first-line chronic lymphocytic leukemia: the phase 2 CAPTIVATE study. Blood Adv 2023; 7:5294-5303. [PMID: 37315225 PMCID: PMC10506056 DOI: 10.1182/bloodadvances.2023010236] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/16/2023] Open
Abstract
We evaluated immune cell subsets in patients with chronic lymphocytic leukemia (CLL) who received first-line therapy with 3 cycles of ibrutinib then 13 cycles of ibrutinib plus venetoclax in the minimal residual disease (MRD) cohort of the CAPTIVATE study (NCT02910583). Patients with Confirmed undetectable MRD (uMRD) were randomly assigned to placebo or ibrutinib groups; patients without Confirmed uMRD were randomly assigned to ibrutinib or ibrutinib plus venetoclax groups. We compared immune cell subsets in samples collected at 7 time points with age-matched healthy donors. CLL cells decreased within 3 cycles after venetoclax initiation; from cycle 16 onward, levels were similar to healthy donor levels (HDL; ≤0.8 cells per μL) in patients with Confirmed uMRD and slightly above HDL in patients without Confirmed uMRD. By 4 months after cycle 16, normal B cells had recovered to HDL in patients randomly assigned to placebo. Regardless of randomized treatment, abnormal counts of T cells, classical monocytes, and conventional dendritic cells recovered to HDL within 6 months (median change from baseline -49%, +101%, and +91%, respectively); plasmacytoid dendritic cells recovered by cycle 20 (+598%). Infections generally decreased over time regardless of randomized treatment and were numerically lowest in patients randomly assigned to placebo within 12 months after cycle 16. Sustained elimination of CLL cells and recovery of normal B cells were confirmed in samples from patients treated with fixed-duration ibrutinib plus venetoclax in the GLOW study (NCT03462719). These results demonstrate promising evidence of restoration of normal blood immune composition with ibrutinib plus venetoclax.
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Affiliation(s)
- Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Josep Carreras Leukaemia Research Institute, Barcelona, Spain
| | | | - Constantine S. Tam
- Department of Hematology, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | | | - Lydia Scarfò
- Division of Experimental Oncology, Università Vita Salute San Raffaele and Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Thomas J. Kipps
- Moores Cancer Center, University of California San Diego, La Jolla, CA
| | | | | | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, CA
| | - James P. Dean
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, CA
| | | | - Michael Choi
- University of California San Diego, La Jolla, CA
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48
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Huber H, Tausch E, Schneider C, Edenhofer S, von Tresckow J, Robrecht S, Giza A, Zhang C, Fürstenau M, Dreger P, Ritgen M, Illmer T, Illert AL, Dürig J, Böttcher S, Niemann CU, Kneba M, Al-Sawaf O, Kreuzer KA, Fink AM, Fischer K, Döhner H, Hallek M, Eichhorst B, Stilgenbauer S. Final analysis of the CLL2-GIVe trial: obinutuzumab, ibrutinib, and venetoclax for untreated CLL with del(17p)/TP53mut. Blood 2023; 142:961-972. [PMID: 37363867 DOI: 10.1182/blood.2023020013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
The final analysis of the open-label, multicenter phase 2 CLL2-GIVe trial shows response and tolerability of the triple combination of obinutuzumab, ibrutinib, and venetoclax (GIVe regimen) in 41 previously untreated patients with high-risk chronic lymphocytic leukemia (CLL) with del(17p) and/or TP53 mutation. Induction consisted of 6 cycles of GIVe; venetoclax and ibrutinib were continued up to cycle 12 as consolidation. Ibrutinib was given until cycle 15 or up to cycle 36 in patients not achieving a complete response and with detectable minimal residual disease. The primary end point was the complete remission rate at cycle 15, which was achieved at 58.5% (95% CI, 42.1-73.7; P < .001). The last patient reached the end of the study in January 2022. After a median observation time of 38.4 months (range, 3.7-44.9), the 36-month progression-free survival was 79.9%, and the 36-month overall survival was 92.6%. Only 6 patients continued ibrutinib maintenance. Adverse events of concern were neutropenia (48.8%, grade ≥3) and infections (19.5%, grade ≥3). Cardiovascular toxicity grade 3 occurred as atrial fibrillation at a rate of 2.4% between cycles 1 and 12, as well as hypertension (4.9%) between cycles 1 and 6. The incidence of adverse events of any grade and grade ≥3 was highest during induction and decreased over time. Progressive disease was observed in 7 patients between cycles 27 and 42. In conclusion, the CLL2-GIVe regimen is a promising fixed-duration, first-line treatment for patients with high-risk CLL with a manageable safety profile.
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Affiliation(s)
- Henriette Huber
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
- Medizinische Klinik III, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Eugen Tausch
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Christof Schneider
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Simone Edenhofer
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Julia von Tresckow
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Can Zhang
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Moritz Fürstenau
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Matthias Ritgen
- Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Thomas Illmer
- Group Practice for Hematology and Oncology, Dresden, Germany
| | - Anna Lena Illert
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan Dürig
- Deptartment of Internal Medicine, St. Josef Krankenhaus Werden, University Medicine Essen, Essen, Germany
| | | | - Carsten U Niemann
- Department of Clinical Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Michael Kneba
- Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Hartmut Döhner
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen Cologne Bonn Duesseldorf, University Hospital of Cologne, Cologne, Germany
| | - Stephan Stilgenbauer
- Sektion CLL, Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany
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49
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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50
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Rigolin GM, Traversa A, Caputo V, Del Giudice I, Bardi A, Saccenti E, Raponi S, Ilari C, Cafforio L, Giovannetti A, Pizzuti A, Guarini A, Foà R, Cuneo A. Additional lesions identified by genomic microarrays are associated with an inferior outcome in low-risk chronic lymphocytic leukaemia patients. Br J Haematol 2023; 202:953-959. [PMID: 37357817 DOI: 10.1111/bjh.18946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/27/2023]
Abstract
We explored the relevance of genomic microarrays (GM) in the refinement of prognosis in newly diagnosed low-risk chronic lymphocytic leukaemia (CLL) patients as defined by isolated del(13q) or no lesions by a standard 4 probe fluorescence in situ hybridization (FISH) analysis. Compared to FISH, additional lesions were detected by GM in 27 of the 119 patients (22.7%). The concordance rate between FISH and GM was 87.4%. Discordant results between cytogenetic banding analysis (CBA) and GM were observed in 45/119 cases (37.8%) and were mainly due to the intrinsic characteristics of each technique. The presence of additional lesions by GM was associated with age > 65 years (p = 0.047), advanced Binet stage (p = 0.001), CLL-IPI score (p < 0.001), a complex karyotype (p = 0.004) and a worse time-to-first treatment in multivariate analysis (p = 0.009). Additional lesions by GM were also significantly associated with a worse time-to-first treatment in the subset of patients with wild-type TP53 and mutated IGHV (p = 0.025). In CLL patients with low-risk features, the presence of additional lesions identified by GM helps to identify a subset of patients with a worse outcome that could be proposed for a risk-adapted follow-up and for early treatment including targeted agents within clinical trials.
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Affiliation(s)
| | - Alice Traversa
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Viviana Caputo
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonella Bardi
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
| | - Elena Saccenti
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
| | - Sara Raponi
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Caterina Ilari
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Luciana Cafforio
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
- GenomeUp S.r.l., Rome, Italy
| | - Agnese Giovannetti
- Clinical Genomics Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, S. Giovanni Rotondo, Italy
| | - Antonio Pizzuti
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Anna Guarini
- Department of Molecular Medicine, Sapienza University, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, St. Anna University Hospital, Ferrara, Italy
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