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Di M, Su CT, Cowan AJ, Gopal AK, Banerjee R. Mitigating time toxicity in lymphoma and multiple myeloma. Leuk Lymphoma 2024; 65:1418-1429. [PMID: 38749027 DOI: 10.1080/10428194.2024.2352086] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/30/2024] [Indexed: 10/02/2024]
Abstract
The concept of time toxicity in oncology refers to the presence of frequent healthcare-related interactions that can interfere with patient well-being. In this review, we examine several manifestations of time toxicity in non-Hodgkin lymphoma and multiple myeloma and discuss their impact on decision-making with patients. For example, time toxicity may influence the choice of chemoimmunotherapy versus lenalidomide-rituximab in follicular lymphoma. In myeloma, it may inform the optimal dosing schedule for proteasome inhibitors and bisphosphonates. In both malignancies, varying time toxicity profiles are a key distinction between chimeric antigen receptor T-cell therapies and bispecific antibodies. We outline the challenges with measuring time toxicity as a trial endpoint but discuss its importance as a consideration for patient care, both in standard-of-care settings and in clinical trials. Throughout the review, we highlight strategies to lower the time toxicity of therapies in lymphoma and myeloma without compromising their efficacy or patient safety.
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Affiliation(s)
- Mengyang Di
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology/Oncology, University of Washington, Seattle, WA, USA
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Christopher T Su
- Division of Hematology/Oncology, University of Washington, Seattle, WA, USA
- Hutchinson Institute for Cancer Outcomes Research, Seattle, WA, USA
| | - Andrew J Cowan
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology/Oncology, University of Washington, Seattle, WA, USA
| | - Ajay K Gopal
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology/Oncology, University of Washington, Seattle, WA, USA
| | - Rahul Banerjee
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology/Oncology, University of Washington, Seattle, WA, USA
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2
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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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Wolska-Washer A, Robak P, Witkowska M, Robak T. Metabolic and toxicological considerations of Bruton's tyrosine kinase inhibitors for the treatment of chronic lymphocytic leukemia/small lymphocytic lymphoma. Expert Opin Drug Metab Toxicol 2024; 20:207-224. [PMID: 38516702 DOI: 10.1080/17425255.2024.2334322] [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] [Accepted: 03/20/2024] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Bruton tyrosine kinase inhibitors (BTKi) have been used for the management of human diseases since the approval of the first-in class agent, ibrutinib, by the Food and Drug Administration in 2013 for the treatment of patients with mantle cell lymphoma (MCL). Ibrutinib is a covalent inhibitor along with second-class BTKis: acalabrutinib and zanubrutinib. These well-tolerated agents have transformed the treatment landscape of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). A new class of these inhibitors, non-covalent, might become an answer to the emerging resistance by avoiding the sustained contact with the kinase binding domain. AREAS COVERED This article examines the chemical composition, mechanism of action, metabolic characteristics, and potential toxicity of inhibitors targeting Bruton tyrosine kinase. A comprehensive search was conducted across English-language articles in PubMed, Web of Science, and Google Scholar. EXPERT OPINION Bruton tyrosine kinase inhibitors have greatly enhanced the armamentarium against lymphoid malignancies including CLL/SLL. Their future lies in the choice of appropriate patients who will benefit from the treatment without significant adverse reaction. Combination chemotherapy-free fixed-duration regimens with targeted molecules will allow for MRD-driven approach in patients with CLL/SLL in the near future.
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Affiliation(s)
- Anna Wolska-Washer
- Department of Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Paweł Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Magdalena Witkowska
- Department of Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
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Coombs CC. Frontline Therapy of CLL-Changing Treatment Paradigms. Curr Hematol Malig Rep 2024; 19:65-74. [PMID: 38337108 DOI: 10.1007/s11899-024-00726-x] [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: 01/31/2024] [Indexed: 02/12/2024]
Abstract
PURPOSE OF REVIEW The therapeutic landscape for chronic lymphocytic leukemia (CLL) has undergone a complete makeover following the introduction of highly effective targeted therapies, beginning with ibrutinib which first attained regulatory approval for CLL in 2014. RECENT FINDINGS In recent years, we have seen further refinement of therapeutic options with the development of newer-generation Bruton's tyrosine kinase inhibitors (BTKi) including acalabrutinib and zanubrutinib that improve upon the safety of ibrutinib. Additionally, venetoclax-based approaches, combined with anti-CD20 antibodies, have allowed for time-limited targeted therapeutic strategies which are particularly attractive for certain subsets of patients though have demonstrated efficacy across all subgroups. Lastly, there is an ongoing movement toward the development of time-limited strategies inclusive of both a BTKi and venetoclax that may further widen potential options. CLL patients requiring frontline therapy have a unique burden of choice between highly effective therapies that differ substantially with respect to side effect profiles and schedules. This review will focus on the frontline management of CLL in the setting of these rapidly changing options.
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Affiliation(s)
- Catherine C Coombs
- University of California Irvine, 200 S. Manchester Avenue, Suite 400, Room 428, ZOT 4061, Orange, Irvine, CA, 92868, USA.
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Ikhlef L, Yassine M, Chandouri B, Rivière L, Naves T, Dmytruk N, Gachard N, Jauberteau MO, Gallet PF. Targeting the NTSR2/TrkB oncogenic pathway in chronic lymphocytic leukemia. Sci Rep 2024; 14:6084. [PMID: 38480783 PMCID: PMC10937676 DOI: 10.1038/s41598-024-56663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/08/2024] [Indexed: 03/17/2024] Open
Abstract
Current therapies that target the B-cell receptor pathway or the inhibition of anti-apoptotic proteins do not prevent the progressive forms of chronic lymphocytic leukemia (CLL), have low long-term efficacy and are subject to therapeutic resistance. Deciphering the mechanisms of leukemic cell survival and searching for new specific targets therefore remain major challenges to improve the management of this disease. It was evidenced that NTSR2 (neurotensin receptor 2), through the recruitment of TRKB (tropomyosin related kinase B), induces survival pathways in leukemic B cells. We have investigated the therapeutic potential of this protein complex as a new target. The binding domain of NTSR2 and TRKB was identified and a peptide targeting the latter was designed. The peptide binds TRKB and efficiently decreases the interaction of the two proteins. It is also effectively internalized by CLL-B cells in which it notably affects Src family kinase signaling and anti-apoptotic proteins levels. It demonstrated a cytotoxic effect both in vitro on the MEC-1 cell line and ex vivo on a cohort of 30 CLL patients. Altogether, these results underline the therapeutic potential of the NTSR2/TRKB protein complex as a target in CLL and open new perspectives for the development of targeted therapies.
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Affiliation(s)
- Léa Ikhlef
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
| | - May Yassine
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
| | - Boutaîna Chandouri
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
| | - Léa Rivière
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
| | - Thomas Naves
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
| | - Natalya Dmytruk
- Department of Clinical Hematology, University Hospital of Limoges, Limoges, France
| | - Nathalie Gachard
- Hematology Laboratory, UMR CNRS7276/INSERM 1262, University Hospital of Limoges, Limoges, France
| | - Marie-Odile Jauberteau
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France
- Immunology Laboratory, University Hospital of Limoges, Limoges, France
| | - Paul-François Gallet
- UMR INSERM 1308, CAPTuR, University of Limoges, 2 rue du Docteur Marcland, 87025, Limoges, France.
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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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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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Easaw S, Ezzati S, Coombs CC. SOHO State of the Art Updates and Next Questions: Updates on BTK Inhibitors for the Treatment of Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:697-704. [PMID: 37544810 DOI: 10.1016/j.clml.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
Over the last decade, targeted inhibition of Bruton's tyrosine kinase (BTK) has led to a paradigm shift in the way chronic lymphocytic leukemia (CLL) is managed. BTK inhibitors (BTKi) are broadly classified as covalent BTKI and noncovalent BTKi (cBTKi and ncBTK) Ibrutinib, as the first approved cBTKi, vastly improved outcomes for patients with CLL over prior chemoimmunotherapy regimens. However, long-term use is limited by both intolerance and resistance. The second generation of more selective BTKi were developed to improve tolerability. While these agents have led to an improved safety profile in comparison to Ibrutinib (both acalabrutinib and zanubrutinib), and improved efficacy (zanubrutinib), intolerance occasionally occurs, and resistance remains a challenge. The third generation of BTKi, which noncovalently or reversibly inhibits BTK, has shown promising results in early phase trials and are being evaluated in the phase 3 setting. These drugs could be an effective treatment option in patients with either resistance and intolerance to cBTKi. The most recent development in therapeutic agents targeting BTK is the development of BTK degraders. By removing BTK, as opposed to inhibiting it, these drugs could remain efficacious irrespective of BTK resistance mutations, however clinical data are limited at this time. This review summarizes the evolution and ongoing development of newer BTKi and BTK degraders in the management of CLL, with a focus of future directions in this field, including how emerging clinical data could inform therapeutic sequencing in CLL management.
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Affiliation(s)
| | - Shawyon Ezzati
- California Northstate University College of Medicine, Elk Grove, CA
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