Activity of venetoclax in patients with relapsed or refractory chronic lymphocytic leukaemia: analysis of the VENICE-1 multicentre, open-label, single-arm, phase 3b trial

BACKGROUND

Most patients with chronic lymphocytic leukaemia progress after treatment or retreatment with targeted therapy or chemoimmunotherapy and have limited subsequent treatment options. Response levels to the single-agent venetoclax in the relapsed setting is unknown. We aimed to assess venetoclax activity in patients with or without previous B-cell receptor-associated kinase inhibitor (BCRi) treatment.

METHODS

This multicentre, open-label, single-arm, phase 3b trial (VENICE-1) assessed activity and safety of venetoclax monotherapy in adults with relapsed or refractory chronic lymphocytic leukaemia, stratified by previous exposure to a BCRi. Eligible participants were aged 18 years or older with previously treated relapsed or refractory chronic lymphocytic leukaemia. Presence of del(17p) or TP53 aberrations and previous BCRi treatment were permitted. Patients received 5-week ramp-up to 400 mg of oral venetoclax once daily and were treated for up to 108 weeks, with 2 years follow-up after discontinuation, or optional extended access. The primary activity endpoint was complete remission rate (complete remission or complete remission with incomplete marrow recovery) in BCRi-naive patients. Analyses used the intent-to-treat (ie, all enrolled patients, which coincided with those who received at least one dose of venetoclax). This study was registered with ClinicalTrials.gov, NCT02756611, and is complete.

FINDINGS

Between June 22, 2016, and March 11, 2022, we enrolled 258 patients with relapsed or refractory chronic lymphocytic leukaemia (180 [70%] were male; 252 [98%] were White; 191 were BCRi-naive and 67 were BCRi-pretreated). Median follow-up in the overall cohort was 49·5 months (IQR 47·2-54·1), 49·2 months (47·2-53·2) in the BCRi-naive group, and 49·7 months (47·4-54·3) in the BCRi-pretreated group. Of 191 BCRi-naive patients, 66 (35%; 95% CI 27·8-41·8) had complete remission or complete remission with incomplete marrow recovery. 18 (27%; 95% CI 16·8-39·1) of 67 patients in the BCRi-pretreated group had complete remission or complete remission with incomplete marrow recovery. Grade 3 or worse treatment-emergent adverse events were reported in 203 (79%) and serious adverse events were reported in 136 (53%) of 258 patients in the overall cohort. The most common treatment-emergent adverse event was neutropenia (96 [37%]) and the most common and serious adverse event was pneumonia (21 [8%]). There were 13 (5%) deaths reported due to adverse events; one of these deaths (autoimmune haemolytic anaemia) was possibly related to venetoclax. No new safety signals were identified.

INTERPRETATION

These data demonstrate deep and durable responses with venetoclax monotherapy in patients with relapsed or refractory chronic lymphocytic leukaemia, including BCRi-pretreated patients, suggesting that venetoclax monotherapy is an effective strategy for treating BCRi-naive and BCRi-pretreated patients.

FUNDING

AbbVie.

Both SEPT2 and MLL are down-regulated in MLL-SEPT2 therapy-related myeloid neoplasia

Background

A relevant role of septins in leukemogenesis has been uncovered by their involvement as fusion partners in MLL-related leukemia. Recently, we have established the MLL-SEPT2 gene fusion as the molecular abnormality subjacent to the translocation t(2;11)(q37;q23) in therapy-related acute myeloid leukemia. In this work we quantified MLL and SEPT2 gene expression in 58 acute myeloid leukemia patients selected to represent the major AML genetic subgroups, as well as in all three cases of MLL-SEPT2-associated myeloid neoplasms so far described in the literature.

Methods

Cytogenetics, fluorescence in situ hybridization (FISH) and molecular studies (RT-PCR, qRT-PCR and qMSP) were used to characterize 58 acute myeloid leukemia patients (AML) at diagnosis selected to represent the major AML genetic subgroups: CBFB-MYH11 (n = 13), PML-RARA (n = 12); RUNX1-RUNX1T1 (n = 12), normal karyotype (n = 11), and MLL gene fusions other than MLL-SEPT2 (n = 10). We also studied all three MLL-SEPT2 myeloid neoplasia cases reported in the literature, namely two AML patients and a t-MDS patient.

Results

When compared with normal controls, we found a 12.8-fold reduction of wild-type SEPT2 and MLL-SEPT2 combined expression in cases with the MLL-SEPT2 gene fusion (p = 0.007), which is accompanied by a 12.4-fold down-regulation of wild-type MLL and MLL-SEPT2 combined expression (p = 0.028). The down-regulation of SEPT2 in MLL-SEPT2 myeloid neoplasias was statistically significant when compared with all other leukemia genetic subgroups (including those with other MLL gene fusions). In addition, MLL expression was also down-regulated in the group of MLL fusions other than MLL-SEPT2, when compared with the normal control group (p = 0.023)

Conclusion

We found a significant down-regulation of both SEPT2 and MLL in MLL-SEPT2 myeloid neoplasias. In addition, we also found that MLL is under-expressed in AML patients with MLL fusions other than MLL-SEPT2.

Numerical variation of nucleolar organizer regions after silver staining in domestic and wild Suidae (Mammalia)

Selective silver staining was used to investigate the cellular distribution of numbers of nucleolar organizer regions (NORs) in domestic pigs (Sus scrofa) of eight different breeds, the European wild boar (S. scrofa scrofa), Indonesian wild boar (S. scrofa vittatus), Javan warty pig (S. verrucosus), Sulawesi warty pig (S. celebensis), and pigmy hog (S. salvanius). In the domestic pig as well as in the wild (sub)species of Sus, actively transcribing ribosomal RNA genes were found to be present in the secondary constrictions of chromosome pairs 10 and 8. Chromosomes 10 were consistently Ag-positive. Chromosomes 8 less frequently showed Ag-NORs, resulting in different mean numbers of Ag-NORs per individual animal. Mean Ag-NOR numbers per breed or (sub)species were generally higher in the wild representatives of Sus than in the domestic breeds. The highest mean numbers of Ag-NORs were observed in the Meishan breed and in S. celebensis and S. salvanius. The Meishan breed appears to be conservative in Ag-NOR staining pattern, being more comparable to the Asian wild Suidae than to the European breeds.

Variation in size of Ag-NORs and fluorescent rDNA in situ hybridization signals in six breeds of domestic pig

Variation of the size of silver-stained nucleolar organizer regions (NORs) of chromosomes 10 and 8 was studied in pigs of six breeds (Sus scrofa L.). The silver deposits were quantified by image analysis and the results were normalized for each Ag-NOR chromosome. In general, normalized values for chromosomes 10 were higher than those for chromosomes 8, suggesting that the NOR activity of chromosomes 10 is dominant as compared to that of chromosomes 8. However, high values for chromosomes 8 were found in the Meishan breed and in some Piétrain pigs, indicating a high transcriptional activity of the rRNA genes on these chromosomes. In some pigs, the relative quantities of rDNA in chromosomes 10 and 8 were investigated by fluorescent in situ hybridization and the results were compared with those of the silver staining procedure. It is concluded that Ag-NOR sizes on chromosomes 10 are relatively well correlated to the number of rRNA genes, whereas the absence or the small size of Ag-NORs on chromosomes 8, often observed in pigs, is the result of low NOR activity rather than of absence of rDNA.

[Fluorescence in situ hybridization in the study of chromosomal abnormalities]

Classical cytogenetics has a low resolving power and allows analysis of dividing cells only. In fluorescence in situ hybridization (FISH), a DNA fragment is stained with a fluorescent marker, after which this fragment is brought into contact with a patient's DNA. The stained fragment can bind to a corresponding fragment, revealing its presence or absence. Using FISH, every desired DNA sequence (from a whole chromosome to one gene) can be stained. In this way it is also possible to diagnose microdeletion syndromes, such as the Williams syndrome, the DiGeorge syndrome and submicroscopic chromosome anomalies that play a part in mental handicaps. FISH also allows analysis of non-dividing cells. In this way it is possible for instance rapidly to examine uncultured amniotic fluid cells for the commoner trisomies or to find foetal erythrocytes in a pregnant woman's blood. It is also possible to demonstrate tumour-specific breaking points. By application of FISH to microarrays it is possible to study a large number of genes simultaneously for the presence of a particular number of DNA sequences linked to a clinical abnormality.

Localization of 18S + 28S and 5S ribosomal RNA genes in the dog by fluorescence in situ hybridization

The gene clusters encoding 18S + 28S and 5S rRNA in the dog (Canis familiaris) have been localized by using GTG-banding and fluorescence in situ hybridization. The 18S + 28S rDNA maps to chromosome regions 7q2.5-->q2.7, 17q1.7, qter of a medium-sized, not yet numbered autosome, and Yq1.2-->q1.3. Our data show that there is one cluster of 5S rDNA in the dog, which maps to chromosome region 4q1.4.

Localization of the 18S, 5.8S and 28S rRNA genes and the 5S rRNA genes in the babirusa and the white-lipped peccary

The locations of the genes encoding 18S, 5.8S and 28S rRNA and 5S rRNA were studied in two relatives of the domestic pig, the babirusa (Babyrousa babyrussa) and the white-lipped peccary (Tayassu pecari). In the babirusa, the 18S, 5.8S and 28S rDNA is located on chromosomes 6, 8 and 10. The genes on chromosomes 8 and 10 are actively transcribed, in contrast to those on chromosomes 6. In the white-lipped peccary, this rDNA was found to be located on chromosomes 4 and 8. The genes on both of these pairs of chromosomes are actively transcribed. The 5S rDNA was physically mapped to chromosome 16 in the babirusa, and to chromosome 11 in the white-lipped peccary. These data are compared to similar data obtained for the domestic pig, and confirm previously recognized chromosome homologies.

Porcine alpha-1-antitrypsin (PI): cDNA sequence, polymorphism and assignment to chromosome 7q2.4- > q2.6

A cDNA clone encoding the complete coding sequence for porcine alpha-1-antitrypsin (or alpha 1-protease inhibitor, PI) was isolated and its DNA sequence determined. The cDNA is assumed to encode alpha-1-antitrypsin on the basis of its sequence similarity to the corresponding cDNAs for human, baboon, rat, mouse, sheep and cow. The porcine cDNA clone was used in conjunction with BamHI, KpnI, MspI, SacI, TaqI and XbaI to develop restriction fragment length polymorphism-based genetic markers for linkage mapping in pigs. The cDNA has also been used to map the porcine PI locus to chromosome 7q2.4- > q2.6 by radioactive in situ hybridization. Thus, the PI locus has been added to the developing physical and genetic maps of the porcine genome.

Chromosome homology between the domestic pig and the babirusa (family Suidae) elucidated with the use of porcine painting probes

Homology among three pairs of domestic pig (Sus scrofa) and five pairs of babirusa (Babyrousa babyrussa) autosomes has been demonstrated with the use of porcine painting probes. With the results of this study, in addition to data obtained earlier through the application of banding techniques, correspondence between all individual chromosomes of these two distantly related pigs has been identified.

Localization of four new markers to pig chromosomes 1, 6, and 14 by radioactive in situ hybridization

The genes coding for glucose regulated protein, 78kDal (GRP78), hormone-sensitive lipase (LIPE), plasminogen activator or urokinase (PLAU), and D-amino acid oxidase (DAO) were localized in the pig by radioactive in situ hybridization. GRP78 was mapped to 1q2.10-->q2.13 and LIPE was localized to chromosome 6cen-->q1.2. The genes for PLAU and DAO were both assigned to chromosome 14, in the region q2.4-->q2.6 and q2.1-->q2.3, respectively. The results are compared to mapping data in other mammalian species.

Cytogenetic analysis of cell lines derived from metastases of a mammary carcinoma in a dog

Three cell lines derived from two metastases of a mammary carcinoma in a female dog were analyzed cytogenetically. All three cell lines showed a modal chromosome number of 76, with ranges of 74-77, 72-78, and 73-78. A biarmed chromosome in addition to the X chromosomes was observed in all cells of one cell line, and in a part of the cells of the other two cell lines. Results of banding analyses indicated that this chromosome was identical in the three cell lines, and can thus be considered a clonal marker. Additional biarmed chromosomes have not been reported previously from mammary tumor cells, although their presence is rather common in other canine neoplasms.