Diagnosis and Treatment of Chronic Lymphocytic Leukemia: A Review

Perspectives on Current Challenges and Emerging Approaches for Lymphoma Management From the First Bridging the Gaps in Leukemia, Lymphoma, and Multiple Myeloma Conference

Recent years have brought a much-needed paradigm shift to the management and treatment of mature B-cell lymphomas. Pathophysiologic and clinical heterogeneity within the various subtypes have historically contributed to treatment challenges and differences in outcomes. Novel genomic tools and therapeutic modalities give promise for improved patient outcomes, but are also making treatment planning increasingly complex. To bridge the gaps between therapeutic advancements and clinical practice, an assembly of multidisciplinary hematologic oncology faculty convened to deliberate on the prevailing challenges, knowledge gaps, and controversies in B-cell lymphoma and chronic lymphocytic leukemia management. Many controversies and questions were identified regarding treatment selection, sequencing, and high-risk subtypes. There is a need for head-to-head trials in this therapeutic area to help answer some of these questions. The insights explored and the gaps in knowledge identified by this panel will inform a follow-up conference in 2025 that will employ the modified Delphi method to develop and publish formal consensus recommendations that can provide actionable guidance to practicing clinicians.

Clinical Relevance of Intensive Laboratory Monitoring With Standard Venetoclax Ramp-Up for Chronic Lymphocytic Leukemia: A Real-World Experience

PURPOSE

Venetoclax is the standard of care for chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) but requires intensive monitoring for optimal safety. Clinical relevance of intensive monitoring in practice is unknown, especially for patients with low or intermediate risk for tumor lysis syndrome (TLS).

PATIENTS AND METHODS

A retrospective review was conducted to determine clinical significance of monitoring for TLS during standard ramp-up for patients with CLL/SLL. Patients receiving abbreviated ramp-up, clinical trials, or concurrent Bruton tyrosine kinase inhibitors were excluded. The primary end point was TLS incidence, with secondary end points describing associated clinical interventions.

RESULTS

Fifty-five patients met study criteria. The majority of patients received venetoclax as first-line therapy (58%), with anti-CD20 antibody therapy (82%), and were at low risk of TLS (75%). No clinical TLS events occurred, whereas laboratory TLS occurred in only 1.8% of patients. No patients required antihyperuricemic therapy, and few interventions for hyperphosphatemia or hypocalcemia (3.6% of patients) were required. Additional intravenous fluids were uncommonly required (1.8% of patients), and no unplanned hospitalizations were required.

CONCLUSION

These findings support efforts to reduce intensive monitoring requirements during venetoclax ramp-up for patients with CLL, potentially increasing accessibility of venetoclax.

Unravelling NK cell subset dynamics and specific gene signatures post-ibrutinib therapy in chronic lymphocytic leukaemia via single-cell transcriptomics

BACKGROUND

As part of the innate immune system, NK cells contribute to optimizing cancer immunotherapy strategies and are becoming a focal point in cancer research. However, limited research has been conducted to further investigate changes in NK cell subsets and their critical genes following ibrutinib treatment in CLL patients.

METHODS

Peripheral blood samples from patients clinically and pathologically diagnosed with monoclonal B-cell lymphocytosis (MBL), newly diagnosed with CLL (ND-CLL), postibrutinib-treated patients who achieved a complete response (CR) or partial response (PR), and those with Richter's syndrome (RS) were collected. Single-cell transcriptome sequencing was performed, followed by pseudotemporal analysis and functional enrichment to characterize the NK cell subsets. Mendelian randomization analysis and colocalization analysis were employed to identify key genes. Multiple algorithms were used for immune infiltration analysis, and drug sensitivity analysis was conducted to pinpoint potential therapeutic agents.

RESULTS

Three distinct NK cell subsets were identified: CD56bright_NK cells, CD56dim_NK cells, and a highly cytotoxic CLL_NK subset. The core genes of the CLL_NK subset were elucidated through Mendelian randomization and colocalization analyses. A cell subset-specific novel index (CNI) was constructed based on these core genes and was shown to be capable of predicting responses to immunotherapy. Oncopredictive algorithms and molecular docking screenings further identified semaxanib and ulixertinib as potential therapeutic candidates for CLL.

CONCLUSION

The CLL_NK subset plays a crucial role in the development and progression of CLL. The CNI, derived from its key genes, holds promise as a predictor of immune therapeutic responses, highlighting the significance of CLL_NK subset dynamics and their genetic underpinnings in CLL management.

Ibrutinib-Induced Perianal Rash Complicated by Bacterial Infection in a Patient With Chronic Lymphocytic Leukemia: A Case Report and Literature Review

Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is widely used in the treatment of chronic lymphocytic leukemia (CLL). However, its use is associated with a range of adverse effects, including cutaneous manifestations. We present a case of a 74-year-old male with CLL who developed a perianal rash following four years of ibrutinib therapy. The rash progressively worsened due to a superimposed bacterial infection, resulting in perianal cellulitis with bleeding, severe pain, and difficulty passing stools. The patient was started on antibiotics, and ibrutinib was discontinued. This case highlights an unusual presentation of ibrutinib-induced skin toxicity in the perianal region, complicated by bacterial infection, and underscores the importance of early recognition and management. To the best of our knowledge, this is the first report of such a manifestation, contributing new insights into the spectrum of ibrutinib-associated cutaneous adverse effects.

Medical- and Implant-Related Complications Following Total Joint Arthroplasty in Patients Who Have Chronic Lymphocytic Leukemia

BACKGROUND

Chronic lymphocytic leukemia (CLL) is highly prevalent in the total joint arthroplasty age group but has not been properly evaluated. This study aimed to assess the following: 1) 90-day medical complications, 2) implant-related complications, 3) healthcare utilization, and 4) time to revision in CLL and non-CLL total joint arthroplasty.

METHODS

The CLL cases undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) were identified using diagnostic and procedural codes. The CLL TKA and THA patients were matched in a 1:5 ratio, with controls based on demographics and comorbidities. The outcomes included 90-day medical complications, 2-year implant complications, length of stay, 90-day readmission, and time to revision.

RESULTS

The CLL TKA patients had significantly higher odds of 90-day medical complications compared to controls, notably pneumonia (OR [odds ratio], 9.2; CI [confidence interval], 7.1 to 12.0; P < 0.001) and myocardial infarction (OR, 5.5; CI, 3.9 to 7.9; P < 0.001). Similarly, CLL THA patients had greater odds of 90-day medical complications, especially pneumonia (OR 10.0; CI 8.2 to 12.2; P < 0.001) and acute kidney injury (OR 6.3; CI 5.1 to 7.8; P < 0.001). The CLL TKA patients faced higher odds of periprosthetic fracture, mechanical loosening, and prosthetic joint infection, while THA patients had increased periprosthetic fractures. Revisions occurred earlier for THA than TKA (337 ± 547 versus 643 ± 774 days). The CLL patients had longer length of stay(TKA: 5.9 ± 6.5 versus 3.1 ± 1.6 days; P < 0.001) (THA: 6.3 ± 12.9 versus 3.0 ± 2.4; P < 0.001) and higher 90-day readmission rates (OR, 1.3; CI, 1.1 to 1.5, P < 0.001).

CONCLUSIONS

Orthopaedic surgeons should consider CLL status for informed patient counseling and complications mitigation.

The journey of patients with diffuse large B-cell lymphoma: from symptoms to diagnosis

Symptoms of lymphomas include peripheral lymphadenopathy, B-symptoms, and other organ-specific symptoms; however, data on initial symptoms incidence in diffuse large B-cell lymphoma (DLBCL) remain limited. We aimed to investigate real-world patterns of initial DLBCL symptoms, correlating them with baseline characteristics and symptom onset-to-diagnosis interval. Patients with DLBCL diagnosed between 2010 and 2021 receiving R-CHOP were screened. 706 individuals with reported initial symptoms were analyzed. 682 (97%) patients had documented symptoms; remaining 24 patients (3%) had incidental findings discovered during examinations for unrelated reasons. Abdominal/gastrointestinal complaints were the most prevalent symptoms (26%), followed by peripheral lymphadenopathy (22%), and B-symptoms (13%). The median symptom-to-diagnosis interval was 10 weeks. Peripheral lymphadenopathy and testicular tumors correlated with low-risk characteristics, with testicular DLBCL featuring a shorter symptom-to-diagnosis interval. Limb pain/swelling and back pain were associated with high-risk characteristics and prolonged symptom-to-diagnosis interval. This analysis enhances our understanding of DLBCL symptomatology, aiding in timely recognition and management.

Disease-modifying strategies: Targeting protein kinases in multiple sclerosis and other autoimmune disorders

A wide variety of immunomodulatory therapies are already available for the treatment of multiple sclerosis (MS). Through fundamental insights from basic research with a gain of knowledge in the pathological processes underlying MS, the exploration of additional medical compounds within clinical trials has been ignited. Emerging novel medications with innovative mechanisms of action are being introduced. Those mechanisms of action include a broad therapeutic spectrum of substances targeting various protein kinases, some of which could also be used for the treatment of other autoimmune-mediated diseases. The advancement of new compounds could therefore enable a more personalized approach in treating MS, taking into consideration patients' co-existing autoimmune-mediated diseases. In this review, we discuss potential compounds targeting protein kinases, currently under investigation in clinical trials for various autoimmune diseases that could become viable treatment options for MS and comorbid autoimmune conditions in the future.

Ibrutinib enhances the bias of T cell responses towards staphylococcal superantigens sustaining inflammation in chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia (CLL) is an uncurable haematological malignancy and is associated with significant infection morbidity. Bruton's tyrosine-kinase inhibitors (e.g., ibrutinib) have improved disease outcomes, but severe infections and poor immunization responses afflict patients. Recently, carriage of the endemic Staphylococcus aureus (SA) was associated with lymphocytosis and decreased survival in CLL patients. We then hypothesized that exposure to staphylococcal superantigens (SAgs), known to promote hyper-inflammatory responses, impairs immunity and increases severe infection risk in CLL patients. Herein, we evaluate the reactivity of T cells and CLL cells to SA SAgs, in cultures derived from ibrutinib-treated and untreated CLL patients. We found that ibrutinib-treated patients had less naive CD8+ T cells (p=0.0348), more checkpoint receptor (TIM-3) expression in memory T cells (p<0.0001), and lower IFNγ/cytokine responses in patient T cells (p≤0.0298). Exposure to SA SAg further increased the accumulation of memory T cells with an exhaustion-phenotype, preferentially in cultures derived from ibrutinib-treated patients (p≤0.0350). Nevertheless, staphylococcal SAgs could not induce regulatory T cells from CLL patients inasmuch as healthy donors (p≤0.0461) and this was associated with accumulation of inflammatory T cells. Significantly, SAg-exposure enhanced inflammatory activation of CLL tumour cells, which acquired CD38, CD40, CD86, while downregulating CD27 (p≤0.005), even in cultures from ibrutinib-treated CLL patients. Thus, we suggest that environmental SAg-exposure promotes the accumulation of pseudo-exhausted T cells, which induce/sustain tumour cell activation, not counteracted by ibrutinib. Our study critically helps understand the chronic inflammatory milieu in CLL patients, with implications for infection morbidity, disease aetiology and future interventions.

Developing a simple clinical risk score for ibrutinib-associated atrial fibrillation

BACKGROUND

Ibrutinib, a Bruton's tyrosine kinase (BTK) inhibitor, is used in the treatment of B-cell malignancies (e.g., chronic lymphocytic leukemia [CLL]). Initial risk stratification of ibrutinib-associated atrial fibrillation (IAAF) may inform atrial fibrillation (AF) surveillance strategies. The performance of existing AF risk scores to predict incident AF among patients newly treated with ibrutinib is unknown.

METHODS

We conducted a single-center retrospective study of all patients without a history of AF who were treated with ibrutinib (2012-2016). Patient demographics were compared between cohorts by the presence of IAAF within 24 months of treatment initiation. First, the predictive ability of established AF risk models was assessed. Secondly, univariate and multivariate analyses were used to create a new IAAF risk model which was compared to established AF risk models by area under the curve (AUC) analysis.

RESULTS

Of 167 patients (66 ± 11 years, 70% male), 24 (14.4%) developed incident IAAF (mean time to IAAF, 7.1 ± 6.3 months). Univariate analysis showed that hypertension (HTN), diabetes (DM), systolic heart failure (HFrEF), and obstructive sleep apnea (OSA) were associated with IAAF. Logistic regression analysis of variables of interest and those with p < 0.1 on univariate analysis demonstrated that left atrial diameter (LAD) > 43 mm and obstructive sleep apnea were independently associated with IAAF. Existing AF risk scores had reasonable performance (AUC, 0.68-0.72). A new simple clinical risk score was developed: OSA 5 points, HFrEF 3 points, DM 2 points, and hyperlipidemia 2 points. This simple IAAF risk score achieved a numerically greater AUC than that of established risk models (AUC = 0.77). There was no statistically significant difference in the AUC performance between risk scores.

CONCLUSION

Among 167 ibrutinib naïve patients, risk factors for incident AF development resemble those of the general population. However, common AF risk models have moderate predictive ability. Large validation studies are needed to confirm the superior IAAF predictive ability of this simple risk score and investigate the incremental predictive value of echocardiographic variables.

Chronic Lymphocytic Leukemia: Investigation of Survival and Prognostic Factors with Drug-Related Remission

Background/Objectives: Understanding the pathogenesis of chronic lymphocytic leukemia (CLL) has led to the development of new prognostic and diagnostic tools, and efforts are underway to extend survival with new prognostic markers and treatment agents. This study aims to evaluate the factors affecting the prognosis and survival of patients with CLL via a retrospective study. Methods: Accordingly, the demographic features of, clinical and laboratory findings for, and hematological parameters and treatment responses of 178 CLL patients who were followed between 1 January 2015 and 31 December 2024 were analyzed before and after treatment protocols were carried out. Results: During the follow-up period, 40.8% of the patients received medical therapy, with 42.5% achieving complete remission, 49.3% experiencing partial remission, and 8.2% demonstrating no response to the treatments. The results demonstrated that an advanced Binet stage, the presence of splenomegaly, a positive direct Coombs test, the presence of a 17p deletion, thrombocytopenia, and elevated creatinine, leukocyte, and lymphocyte counts were associated with increased mortality. Elevated Binet and Rai stages, the existence of 17p deletion, and reduced hemoglobin levels were identified as statistically significant factors. Conclusions: Given the unfavorable prognosis of CLL patients exhibiting a positive direct Coombs test and compromised renal function, further investigations are required to validate the necessity of more rigorous monitoring and, possibly, early intervention. These findings underscore the importance of identifying high-risk factors in CLL to optimize patient management and improve long-term outcomes.

Effects of a strength physical exercise program in chronic lymphocytic leukemia patients on quality of life, mental health, and frailty: a randomized controlled trial study protocol

Background

Chronic lymphocytic leukemia (CLL) is a type of cancer that affects the blood and bone marrow, and it is the most prevalent form of leukemia in adults. Many patients experience symptoms that can significantly impact their quality of life, particularly in terms of physical ability, emotional health, and fatigue. Therapeutic exercise has shown to be an effective intervention for alleviating both physical and psychological symptoms in these patients. Specifically, strength training may help address some common treatment side effects.

Objective

This study aims to evaluate the effects of a therapeutic exercise program, focused on frailty in patients with CLL, along with secondary objectives including impacts on functional capacity, quality of life, psychological status, sleep quality, body composition, anthropometric variables, lipid profile and on proteins related to the immune system and inflammation.

Methods

An open label, randomized controlled trial will be carried out with 36 participants, divided into an intervention group (supervised resistance training twice a week and home exercises) and a control group (home exercise only). The primary outcome measure is fraility, assessed using Short Physical Performance Battery (SPPB). Secondary outcomes include assessments using HADS, FACT-F, EORTC QLQ-C30, EORT QLQ-CLL17.

Results and conclusions

This study will explore how physical exercise can improve quality of life and various health metrics in patients with CLL. By creating customized exercise protocols, the research seeks to boost patient well-being, improve treatment outcomes, and lessen debilitating side effects, ultimately promoting the integration of physical activity into routine care.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT06654206).

Molecular Mechanisms in the Transformation from Indolent to Aggressive B Cell Malignancies

Histological transformation (HT) into aggressive lymphoma is a turning point in a significant fraction of patients affected by indolent lymphoproliferative neoplasms, namely, chronic lymphocytic leukemia (CLL), follicular lymphoma (FL), marginal zone lymphomas (MZLs), and lymphoplasmacytic lymphoma (LPL) [...].

An Incidental Finding of Gain of a Diminished Chromosome 12 Centromere in an Individual with Lymphocytosis: A Case Report and Clinical Implications in Cytogenetic Testing

Background: Fluorescence in situ hybridization (FISH) testing against chromosome 12 centromere (CEN12) is routinely included in the work-up of patients with suspected chronic lymphocytic leukemia (CLL) or monoclonal B-cell lymphocytosis (MBL). However, incidental findings can occur and be challenging. Methods: Interphase and metaphase FISH analyses with various probes, including CEN12 probes from different vendors, and conventional cytogenetics were applied. Results: A CLL FISH panel was performed at the clinician's request on a peripheral blood specimen from a 55-year-old female with fluctuating leukocytosis and lymphocytosis for over six years. An additional diminished CEN12 FISH signal was observed in approximately 70% of the nucleated cells analyzed. Concurrent flow cytometry excluded a diagnosis of CLL or MBL, and karyotyping exhibited a normal female karyotype. Further studies excluded potential cross-hybridization due to limited specificity of the CEN12 probes and revealed the location of the additional diminished CEN12 signal on the centromere of one chromosome 16 homolog (CEN16), without other material from the short arm (12p) or long arm (12q) of chromosome 12 being involved. Conclusions: This is the first case with an "uncertain" trisomy 12 status, presenting a challenge to clinical cytogenetic diagnosis. Although the mechanism for this mosaic "partial trisomy 12" and its clinical impact remain unknown, this case highlights the importance of further investigation using orthogonal methods to clarify incidental findings during diagnostic practice.

Zanubrutinib Versus Bendamustine and Rituximab in Patients With Treatment-Naïve Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Median 5-Year Follow-Up of SEQUOIA

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.SEQUOIA (ClinicalTrials.gov identifier: NCT03336333) is a phase III, randomized, open-label trial that compared the oral Bruton tyrosine kinase inhibitor zanubrutinib to bendamustine plus rituximab (BR) in treatment-naïve patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). The initial prespecified analysis (median follow-up, 26.2 months) and subsequent analysis (43.7 months) found superior progression-free survival (PFS; the primary end point) in patients who received zanubrutinib compared with BR. At a median follow-up of 61.2 months, median PFS was not reached in zanubrutinib-treated patients; median PFS was 44.1 months in BR-treated patients (hazard ratio [HR], 0.29; one-sided P = .0001). Prolonged PFS was seen with zanubrutinib versus BR in patients with mutated immunoglobulin heavy-chain variable region (IGHV) genes (HR, 0.40; one-sided P = .0003) and unmutated IGHV genes (HR, 0.21 [95% CI, 0.14 to 0.33]; one-sided P < .0001). Median overall survival (OS) was not reached in either treatment arm; estimated 60-month OS rates were 85.8% and 85.0% in zanubrutinib- and BR-treated patients, respectively. No new safety signals were detected. Adverse events were as expected with zanubrutinib; rate of atrial fibrillation was 7.1%. At a median follow-up of 61.2 months, the results supported the initial SEQUOIA findings and suggested that zanubrutinib was a favorable treatment option for untreated patients with CLL/SLL.

Effect of POD24 on the prognosis of follicular and other indolent B-cell non-hodgkin lymphomas

Indolent B-cell non-Hodgkin lymphomas(B-NHL) encompass a heterogeneous category of lymphomas characterized by a wide range of pathological subtypes. With the application of chemoimmunotherapy with rituximab (R-chemo), the prognosis of patients has improved considerably, with a 10-year survival rate of 60-80%. Despite these advancements, a significant number of patients still experience disease progression during or shortly after initial treatment. Those who progress within the first 24 months (POD24) continue to face a notably worse prognosis. This study aims to explore the significance of POD24 in predicting the prognosis of different subtypes of indolent B-cell NHL through a comprehensive literature review. The investigation extends to examining the existing prognostic assessment tools and evaluating the interrelationship between POD24 and these tools. By synthesizing relevant research findings, this study seeks to contribute to the current understanding of the role POD24 plays in prognostic evaluation and its potential implications in guiding clinical decision-making for patients with indolent B-cell NHL.

Leveraging the Immunomodulatory Potential of Ibrutinib for Improved Outcomes of T Cell-Mediated Therapies of B Cell Malignancies: A Narrative Review

Standard treatment options for B cell malignancies include immunochemotherapies and/or targeted therapies, which often provide temporary disease remission. However, many patients do not achieve complete remission with these treatments, develop resistance, and eventually experience disease relapse. New immunomodulatory treatments, such as T cell-based therapies, show promise in treating various types of blood cancers, including B cell malignancies. However, their effectiveness is often limited by the immunosuppressive tumor microenvironment and altered function of patient-derived T cells. Ibrutinib, a Bruton tyrosine kinase inhibitor, has been shown to restore immune balance and function in patients with chronic lymphocytic leukemia. Ibrutinib is being studied as adjuvant or combinatorial therapy with chimeric antigen receptor (CAR) T cells or T cell-engaging bispecific antibodies for the treatment of B cell malignancies. Current evidence suggests that ibrutinib could be beneficial when used before, during, or after CAR T cell administration, potentially providing higher complete response rates and reduced toxicity. In conclusion, existing evidence strongly supports the combined use of ibrutinib and T cell therapies. However, additional clinical trials are needed to further validate the effectiveness of this treatment strategy in patients with various B cell malignancies.

Comparative Safety of Ibrutinib Versus Zanubrutinib in Patients With Chronic Lymphocytic Leukemia: A Prospective Cohort Study

This study compares the safety profiles of two Bruton's tyrosine kinase (BTK) inhibitors, Ibrutinib and Zanubrutinib, in patients with chronic lymphocytic leukemia (CLL). While Ibrutinib has transformed CLL treatment, it is associated with significant adverse events (AEs). Zanubrutinib, a second-generation BTK inhibitor, offers potential for improved safety. In this prospective study, 200 CLL patients were enrolled, with 100 receiving Ibrutinib and 100 receiving Zanubrutinib. Baseline characteristics such as age, sex, body mass index (BMI), Eastern Cooperative Oncology Group (ECOG) performance status, and genetic factors were evaluated. AEs and serious AEs (SAEs) were tracked and graded using the Common Terminology Criteria for Adverse Events (CTCAE). Multivariate logistic regression models were conducted to determine predictors of SAE and AEs grade ≥ 3. Adjusted odds ratio (aOR) and 95% confidence interval (CI) were reported. The mean ages of the Ibrutinib and Zanubrutinib groups were 49.65 and 49.16 years, respectively (p = 0.285). The Zanubrutinib group had a higher percentage of patients with worse ECOG status (71% vs. 57%, p = 0.039). Fewer Zanubrutinib patients experienced severe AEs (4% vs. 9%, p = 0.152) or SAEs (8% vs. 17%, p = 0.054). Neutropenia occurred only in the Ibrutinib group (3%). Subgroup analysis showed a higher complication rate with Zanubrutinib in non-refractory patients (11.40% vs. 5.26%, p = 0.065). Stage III CLL was a protective factor of grade ≥ 3 AEs (aOR = 0.007; 95% CI: 0.0003-0.1829) and SAE (aOR = 0.015; 95% CI: 0.001-0.177). While ECOS status (2 vs. 3) resulted in reduced risk of SAE, chromosome 17p deletion emerged as the main risk factor of SAE (aOR = 6.40; 95% CI: 1.33-30.79). Zanubrutinib demonstrated a more favorable safety profile than Ibrutinib, with fewer severe adverse events. It may be a safer alternative for CLL patients, particularly those at higher risk for complications from BTK inhibitors. However, these differences stemmed from variability in baseline clinical characteristics rather than the interventions themselves.

Evidence-based investigation of the efficacy and safety of venetoclax-containing regimens versus chemoimmunotherapy in chronic lymphocytic leukemia

Randomized controlled trials (RCTs) comparing the treatment outcomes and adverse events of venetoclax-containing regimens with chemoimmunotherapy in chronic lymphocytic leukemia (CLL) are scarce, and the available data are heterogeneous. We carried out a meta-analysis and systematic review to explore the efficacy and safety of these novel venetoclax combination therapies in CLL patients. Five RCTs (11 articles) involving 2481 CLL patients were included. Through a detailed pooled odds ratio analysis, it was revealed that, in terms of 1-year to 5-year progression-free survival (PFS) and overall survival (OS), venetoclax combination therapy demonstrated an obvious superiority over chemoimmunotherapy. In patients with unmutated immunoglobulin heavy chain variable region gene (IGHV), the 1-year to 5-year PFS was notably better with venetoclax combination therapy. In those with mutated IGHV, the 1-year to 4-year PFS was also improved with the use of venetoclax-containing regimens, although the 5-year PFS was comparable between the two treatment regimens. In patients with del(17p) and/or TP53 mutations, the 2-year, 3-year, and 4-year PFS were significantly superior with venetoclax-containing regimens. There were no significant differences between venetoclax-containing regimens and chemoimmunotherapy in all grade 3 or 4 adverse events, neutropenia, thrombocytopenia, infections, pneumonia, sepsis, infusion-related reactions, or tumor lysis syndrome. Venetoclax-containing regimens were associated with a decreased risk of anemia, leukopenia, febrile neutropenia, and pyrexia, but an increased risk of diarrhea and hypertension. Our results demonstrate the superiority of venetoclax-containing regimens in CLL patients, particularly in those with unmutated IGHV and del(17p) and/or TP53 mutations.

The Heterogeneity of 13q Deletions in Chronic Lymphocytic Leukemia: Diagnostic Challenges and Clinical Implications

Chronic lymphocytic leukemia (CLL) is the most common type of adult leukemia, particularly in Western countries. CLL can present indolently or aggressively, influenced by various factors, including chromosomal alterations. Fluorescent in situ hybridization (FISH), targeting specific genes/loci frequently affected in CLL patients, has established a standard for stratifying five CLL prognostic groups: del(11q)/ATM, trisomy 12, del(13q) as a sole aberration, del(17p)/TP53, and normal CLL FISH panel results. Among these, del(13q) as a sole aberration is associated with a favorable prognosis, while the others are considered intermediate (normal CLL FISH panel result and trisomy 12) or unfavorable (del(11q)/ATM and del(17p)/TP53) prognostic markers. However, significant heterogeneity in del(13q) aberrations has been observed among CLL patients with isolated del(13q), which should be considered when predicting prognosis and planning clinical management for individual CLL patients with this aberration. This review discusses the variations in del(13q) aberrations in CLL, including a minimally deleted region (MDR), the anatomic sizes of deleted 13q regions, affected alleles, the clone sizes of del(13q), and their dynamic changes during disease progression. The impact of del(13q) heterogeneity on various diagnostic tests such as karyotyping, the FISH panel, chromosomal microarray (CMA), and optical genome mapping (OGM), prognostic prediction, and clinical management is illustrated through authentic clinical scenarios.

High-Accuracy and Lightweight Image Classification Network for Optimizing Lymphoblastic Leukemia Diagnosisy

Leukemia is a hematological malignancy that significantly impacts the human immune system. Early detection helps to effectively manage and treat cancer. Although deep learning techniques hold promise for early detection of blood disorders, their effectiveness is often limited by the physical constraints of available datasets and deployed devices. For this investigation, we collect an excellent-quality dataset of 17,826 morphological bone marrow cell images from 85 patients with lymphoproliferative neoplasms. We employ a progressive shrinking approach, which integrates a comprehensive pruning technique across multiple dimensions, including width, depth, resolution, and kernel size, to train our lightweight model. The proposed model achieves rapid identification of acute lymphoblastic leukemia, chronic lymphocytic leukemia, and other bone marrow cell types with an accuracy of 92.51% and a throughput of 111 slides per second, while comprising only 6.4 million parameters. This model significantly contributes to leukemia diagnosis, particularly in the rapid and accurate identification of lymphatic system diseases, and provides potential opportunities to enhance the efficiency and accuracy of medical experts in the diagnosis and treatment of lymphocytic leukemia.

Comparing the efficacy and safety of first-line treatments for chronic lymphocytic leukemia: a network meta-analysis

BACKGROUND

The chronic lymphocytic leukemia treatment strategies have transitioned from chemotherapy and chemoimmunotherapy to chemotherapy-free regimens. Frequentist network meta-analysis allows for direct and indirect comparisons between different treatments.

METHODS

Randomized controlled trials assessing first-line treatments were included. Outcomes were progression-free survival (PFS), overall survival, undetectable minimal residual disease, objective response rate, and adverse events. Studies with comparable characteristics also underwent subgroup analysis, stratifying by age, comorbidities, IGHV status, and cytogenetic abnormalities.

RESULTS

A total of 30 eligible trials involved 12 818 patients, and 30 treatments were included. Acalabrutinib demonstrated a PFS advantage over ibrutinib and obinutuzumab-venetoclax in patients aged older than 65 years or with unmutated IGHV. In younger patients with comorbidities, acalabrutinib-obinutuzumab had superior PFS compared with ibrutinib-obinutuzumab, ibrutinib-venetoclax, and obinutuzumab-venetoclax. For older patients with comorbidities, acalabrutinib and acalabrutinib-obinutuzumab outperformed obinutuzumab-venetoclax without statistically difference between them. Minimal residual disease-guided ibrutinib-venetoclax surpassed obinutuzumab-venetoclax in patients without comorbidities. Ibrutinib-obinutuzumab exhibited extended PFS benefits compared with obinutuzumab-venetoclax in patients with mutated IGHV or with del(17p) and/or TP53 mutations. Ibrutinib-venetoclax and ibrutinib-obinutuzumab had lower neutropenia rates than obinutuzumab-venetoclax. Ibrutinib-venetoclax had fewer infections than acalabrutinib and acalabrutinib-obinutuzumab. Acalabrutinib-obinutuzumab caused less diarrhea than ibrutinib-venetoclax but more headaches than ibrutinib-obinutuzumab and obinutuzumab-venetoclax. Obinutuzumab-venetoclax had lower hypertension rates than ibrutinib-obinutuzumab. Ibrutinib-venetoclax had fewer arthralgia than acalabrutinib-obinutuzumab. For any grade secondary primary neoplasms, ibrutinib-venetoclax and obinutuzumab-venetoclax was less than acalabrutinib-obinutuzumab.

CONCLUSION

Tailored chemotherapy-free regimens can be selected based on age, comorbidities, IGHV status, and cytogenetic abnormalities to optimize treatment outcomes while considering different adverse events spectra.

Flavonoids as Chemosensitizers in Leukemias

Flavonoids, a diverse group of natural compounds abundant in plants, fruits, and seeds, are not only responsible for the vibrant colors, fragrances, and flavors found in nature but also possess significant health benefits. Representing a secondary metabolite, these phytonutrients contribute to overall well-being. They have garnered considerable interest due to their diverse biological roles, encompassing antioxidant, anti-inflammatory, and anticancer properties. Flavonoids exert anticancer properties by interfering with different signaling pathways and molecules. Also, they have been demonstrated to exert chemosensitization features, where flavonoids may enhance the effectiveness of chemotherapy, and hold promise for improving cancer treatment outcomes as they have been discovered to make cancer cells more responsive to treatment. Understanding their influence on the regulation of cellular signaling provides a foundation for exploring their potential in combination with different chemotherapy agents and their possible single use for cancer treatment. Besides, they are believed to present a cost-effective approach to cancer therapeutics with possible implications for reducing the side effects of the current chemotherapy regimens, which can be a great therapeutic strategy for treating cancer types, including leukemia. This chapter explores potential approaches for creating anticancer treatments, focusing on leukemia, through integrating flavonoid nutraceuticals with traditional chemotherapy agents.

Overview of the Different Classes of Small RNAs During B-Cell Development

B lymphocytes (B cells) are a type of white blood cell that play an essential role in the adaptive immune response. They are derived from pluripotent hematopoietic stem cells and undergo several developmental stages in the bone marrow and secondary lymphoid organs to become effector cells. B cells can act as antigen-presenting cells, secrete cytokines, generate immunological memory as memory B cells, and produce and secrete high-affinity antibodies as plasma B cells.B-cell development occurs in discontinuous steps within specific organs and niche environments, progressing through checkpoints controlled by the relative levels of numerous transcription factors, cytokines, and surface receptors. These complex interactions of distinct developmental programs operate through balanced control mechanisms rather than simple "on/off" signals.Over the past two decades, much has been learned about short non-coding RNA (ncRNA) molecules that play a critical role in fine-tuning gene expression by targeting specific messenger RNAs (mRNAs) for degradation or translational repression. In the intricate orchestration of B-cell development, ncRNAs contribute to the delicate balance between proliferation, differentiation, and apoptosis by influencing key checkpoints in the maturation process.Therefore, in this chapter, I will review the role of different classes of small ncRNAs, including microRNAs, glycoRNAs, tRNA-derived fragments, and ribosomal RNA-derived fragments, in modulating gene expression at the post-transcriptional level and their contribution to the intricate regulatory network that controls B-cell maturation.

An unusual oral manifestation of chronic lymphocytic leukemia: A case report and review of the literature

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most prevalent type of leukemia in adults, characterized by the accumulation of mature-appearing, immunologically dysfunctional B lymphocytes in the blood, bone marrow, and secondary lymphoid organs. Oral manifestations of CLL are infrequent and less documented. The authors present a case of CLL in remission with multiple lesions of the palatal mucosa and a literature review of all reported cases of oral manifestations of CLL.

CASE DESCRIPTION

A 75-year-old woman with hereditary hemochromatosis, hypogammaglobulinemia, and CLL in remission on ibrutinib sought treatment for multiple, asymptomatic, erythematous papules of the palatal mucosa incidentally noticed by her general dentist. A complete blood count revealed mild absolute lymphocytosis. Extraoral examination was unremarkable. A biopsy of 1 of the palatal mucosa lesions was obtained. Histopathologic examination revealed a focus of B-cell CLL, supported by immunohistochemistry showing the cells positive for cluster of differentiation 5, cluster of differentation 43, PAX-5, BCL-2, and LEF-1. The patient's hematologist-oncologist ruled out ibrutinib resistance due to Bruton tyrosine kinase (BTK) or PLCG2 mutations. Ibrutinib treatment was continued, and at the 1-year follow-up, only erythema of the palatal mucosa was observed.

PRACTICAL IMPLICATIONS

Oral health care providers should include CLL in the differential diagnosis for multiple erythematous papules of the palatal mucosa, particularly in the presence of absolute lymphocytosis. Early recognition of oral manifestations associated with CLL can prompt a timely referral.

Transcriptomic clustering of chronic lymphocytic leukemia: molecular subtypes based on Bruton's tyrosine kinase expression levels

Historically, CLL prognostication relied on disease burden, reflected in clinical stage. Later, chromosome abnormalities and genomics suggested several CLL subtypes which were aligned with response to therapy. Gene expression profiling data identified pathways associated with CLL progression. We hypothesized that transcriptome and proteome may identify functional omics associated with CLL nosology. As a test cohort, we utilized publicly available treatment-naïve CLL transcriptomics data (n = 130) and did consensus clustering that identified BTK-expression-based clusters. The BTK-High and BTK-Low clusters were validated in public and our in-house databases (n = >550 CLL patients). To associate with functional relevance, we took samples from 151 previously treated patient with CLL and analyzed them using RNA sequencing and reverse-phase protein array. Transcript levels were strongly correlated with BTK protein levels. BTK-High subtype showed increased CCL3/CCL4 levels and disease burden such as high WBC. BTK-Low subtype showed down-regulated mRNA/proteins of DNA-repair pathway and increased DNA-damage-response, which may have contributed to enrichment of inflammatory pathway. BTK-Low subtype was rich in proapoptotic gene and protein expression and relied less on BCR pathway. High-BTK subgroup was enriched in replication/repair pathway and transcription machinery. In conclusion, profiling of 5 datasets of ~700 patients revealed unique BTK-associated expression clusters in CLL.

Efficacy and challenges involving combination therapies in CLL

Chronic lymphocytic leukemia (CLL), a malignant tumour, is characterized by expansion of mature monoclonal B lymphocytes expressing CD23 and CD5 in secondary lymphocytic organs, blood, and bone marrow. Here, we provide an in-depth review of CLL, emphasizing its pathophysiology, cytogenic changes, and treatment strategies, particularly the efficacy and challenges of treatments, such as Bruton tyrosine kinase (BTK) inhibitors, B cell lymphoma 2 (BCL2) inhibitors, and phosphatidylinositol 3-kinase (PI3K) inhibitors, as well as the need to understand their role in managing disease progression, chemoresistance, and intolerance. In addition, we explore efficacy based on patient response and comparison between monotherapy and combination therapy. We also highlight the need for innovative strategies to overcome treatment resistance and enhance patient outcomes.

First case of acute promyelocytic leukemia with TFG-RARA achieved complete remission treated with venetoclax and all-trans retinoic acid

Variant acute promyelocytic leukemia (vAPL) represents a certain type of APL case whose specific fusion proteins, which are relevant but atypical variants, may fail to be identified by polymerase chain reaction (PCR) and fluorescence in situ hybridization (FISH) and requires identification through next-generation sequencing (NGS) or RNA sequencing (RNA-seq). These patients often show insensitivity to arsenic trioxide (ATO) or all trans-retinoic acid (ATRA) and therefore exhibit unclear prognosis. Venetoclax (VEN), an oral small-molecule B-cell lymphoma 2 (BCL-2) inhibitor, demonstrates effectiveness and safety as a cytoreduction therapy for pediatric APL and has shown some promising effect on relapsed or refractory APL. However, only a few cases have been reported on the treatment of vAPL with a single drug or multiple drugs combined with VEN. Therefore, this study reported the first vAPL case with the TFG-RARA fusion gene, who achieved complete remission (CR) with oral administration of VEN and ATRA, and remained CR till submission. Our study indicated that VEN may have a good therapeutic effect and contribute to a better prognosis of vAPL and warranted further application among APL patients.

Warehouse-based, immunopeptidome-guided design of personalised peptide vaccines shows feasibility in clinical trial evaluation in CLL patients

Cancer peptide vaccination represents a promising therapeutic approach, but has been hampered by lack of suitable antigens and restricted applicability due to different HLA backgrounds of individual patients. We here introduce a novel warehouse-based concept for composition of personalized peptide vaccines and report on its successful application in a Phase II clinical trial in patients with chronic lymphocytic leukemia (CLL) after first-line therapy. 26 CLL patients in at least partial remission (PR) after 6 months of immuno-chemotherapy were vaccinated with a personalized vaccine compiled from a premanufactured peptide warehouse comprising immunopeptidome-defined CLL-associated peptides. Primary objective was evaluation of immunogenicity, secondary objectives were safety and minimal residual disease (MRD) response. Immunopeptidome-guided vaccine composition was throughout successful, proving the feasibility of warehouse-based vaccine design. Vaccination was well tolerated, with local injection site reactions being the most common adverse event. Only few patients showed vaccine-induced T cell responses, attributable to their inability to mount strong immune responses due to immune-chemotherapy and lack of potent adjuvant formulations. Both issues are addressed within a follow-up trial (NCT04688385), combining the immunopeptidome-guided warehouse-based vaccine design reported here with a potent novel adjuvant evaluating personalized multi- peptide vaccination in CLL patients under T cell supportive BTK inhibitor therapies.

Clinical trial registration

www.clinicaltrialsregister.eu, identifier NCT02802943.

The efficacy and safety of PI3K and AKT inhibitors for patients with cancer: A systematic review and network meta-analysis

BACKGROUND

Inhibiting PI3K/AKT pathway activation may hinder the occurrence and progression of cancer. The aim of this study was to evaluate the efficacy and safety of the PI3K/AKT inhibitors and determine the most appropriate inhibitor for different cancer types.

METHODS

Electronic databases up to June 2024 were used to examine the efficacy and safety of PI3K inhibitors (alpelisib, copanlisib, duvelisib, and idelalisib) and AKT inhibitors (capivasertib, ipatasertib and MK-2206) for the treatment of cancer. Data was assessed with a random-effect pairwise and network meta-analysis. Randomized controlled trials and retrospective studies were eligible if they compared PI3K or AKT inhibitors with non-PI3K/AKT controls with no restriction.

RESULTS

The results were based on 34 studies from 34 published articles and 6 online registration trials (6710 patients). According to pairwise meta-analysis, PI3K/AKT inhibitors showed to be highly effective, especially for treating mutant cancers, but had poor safety profiles. According to our network meta-analysis, PI3K/AKT inhibitors, especially the AKT inhibitor capivasertib, are effective for treating solid cancers such as breast cancer (BC). Moreover, PI3K inhibitors, especially idelalisib, were effective for treating hematologic cancers such as chronic lymphocytic leukemia (CLL).

CONCLUSIONS

The PI3K/AKT inhibitors are effective in patients with genetic mutations. For solid cancers such as BC, capivasertib was efficacy and safety. For hematological cancers represented by CLL, idelalisib was efficacy and safety. The above studies can be used when recommending appropriate targeted therapies for patients with different cancer types.

Inhibiting Bruton's Tyrosine Kinase to Counteract Chemoresistance and Stem Cell-Like Properties in Osteosarcoma

Osteosarcoma, a highly aggressive bone cancer, often develops resistance to conventional chemotherapeutics, leading to poor prognosis and survival rates. The malignancy and chemoresistance of osteosarcoma pose significant challenges in its treatment, highlighting the critical need for novel therapeutic approaches. Bruton's tyrosine kinase (BTK) plays a pivotal role in B-cell development and has been linked to various cancers, including breast, lung, and oral cancers, where it contributes to tumor growth and chemoresistance. Despite its established importance in these malignancies, the impact of BTK on osteosarcoma remains unexplored. Our study delves into the expression levels of BTK in osteosarcoma tissues by data from the GEO and TCGA database, revealing a marked increase in BTK expression compared with primary osteoblasts and a potential correlation with primary site progression. Through our investigations, we identified a subset of osteosarcoma cells, named cis-HOS, which exhibited resistance to cisplatin. These cells displayed characteristics of cancer stem cells (CSCs), demonstrated a higher angiogenesis effect, and had an increased migration ability. Notably, an upregulation of BTK was observed in these cisplatin-resistant cells. The application of ibrutinib, a BTK inhibitor, significantly mitigated these aggressive traits. Our study demonstrates that BTK plays a crucial role in conferring chemoresistance in osteosarcoma. The upregulation of BTK in cisplatin-resistant cells was effectively countered by ibrutinib. These findings underscore the potential of targeting BTK as an effective strategy to overcome chemoresistance in osteosarcoma treatment.

A Markov model-based cost-effectiveness analysis comparing zanubrutinib to ibrutinib for treating relapsed and refractory chronic lymphocytic leukemia

OBJECTIVE

This article examined the cost-effectiveness of zanubrutinib and ibrutinib for managing relapsed and refractory chronic lymphocytic leukemia from the viewpoint of payers in China and the US.

METHODS

Markov models were employed to conduct comparisons. Baseline characteristics and clinical data were extracted from the ALPINE study. The cost-effectiveness outcome indicators encompassed cost, quality-adjusted life years, and the incremental cost-effectiveness ratio.

RESULTS

The Markov model analysis revealed that the zanubrutinib group incurred an incremental cost per patient of $-24,586.53 compared to the ibrutinib group. The zanubrutinib group exhibited an incremental utility per capita of 0.28 quality-adjusted life years, resulting in an incremental cost-effectiveness ratio of $-88,068.16 per quality-adjusted life year, which is lower than the payment threshold in China. The willingness-to-pay value in China for 2022 was three times the country's gross domestic product per capita. In the US, patients in the zanubrutinib group experienced per capita incremental costs of $-79,421.56, per capita incremental utility of 0.28 quality-adjusted life years, and an incremental cost-effectiveness ratio of $-284,485.45 per quality-adjusted life year.

CONCLUSION

For Chinese payers, zanubrutinib exhibited superior cost-effectiveness compared to ibrutinib. Zanubrutinib proved to be a more affordable option for US payers when considering the payment threshold.

Venetoclax-obinutuzumab for previously untreated chronic lymphocytic leukemia: 6-year results of the randomized phase 3 CLL14 study

ABSTRACT

In the CLL14 study, patients with previously untreated chronic lymphocytic leukemia (CLL) and coexisting conditions were randomized to 12 cycles of venetoclax-obinutuzumab (Ven-Obi, n = 216) or chlorambucil-obinutuzumab (Clb-Obi, n = 216). Progression-free survival (PFS) was the primary end point. Key secondary end points included time-to-next-treatment (TTNT), rates of undetectable minimal residual disease (uMRD), overall survival (OS), and rates of adverse events. Patient reported outcomes of time until definitive deterioration (TUDD) in quality of life (QoL) were analyzed. At a median observation time of 76.4 months, PFS remained superior for Ven-Obi compared with Clb-Obi (median, 76.2 vs 36.4 months; hazard ratio [HR], 0.40; 95% confidence interval [CI], 0.31-0.52; P < .0001). Likewise, TTNT was longer after Ven-Obi (6-year TTNT, 65.2% vs 37.1%; HR, 0.44; 95% CI, 0.33-0.58; P < .0001). In the Ven-Obi arm, presence of del(17p), unmutated immunoglobulin heavy-chain variable region, and lymph node size of ≥5 cm were independent prognostic factors for shorter PFS. The 6-year OS rate was 78.7% in the Ven-Obi and 69.2% in the Clb-Obi arm (HR, 0.69; 95% CI, 0.48-1.01; P = .052). A significantly longer TUDD in global health status/QoL was observed in the Ven-Obi than in the Clb-Obi arm (median, 82.1 vs 65.1 months; HR, 0.70; 95% CI, 0.51-0.97). Follow-up-adjusted second primary malignancies incidence rates were 2.3 and 1.4 per 1000 patient-months in the Ven-Obi and Clb-Obi arm, respectively. The sustained long-term survival and QoL benefits support the use of 1-year fixed-duration Ven-Obi in CLL. This trial was registered at www.ClinicalTrials.gov as #NCT02242942.

Histone deacetylase inhibitors for leukemia treatment: current status and future directions

Leukemia remains a major therapeutic challenge in clinical oncology. Despite significant advancements in treatment modalities, leukemia remains a significant cause of morbidity and mortality worldwide, as the current conventional therapies are accompanied by life-limiting adverse effects and a high risk of disease relapse. Histone deacetylase inhibitors have emerged as a promising group of antineoplastic agents due to their ability to modulate gene expression epigenetically. In this review, we explore these agents, their mechanisms of action, pharmacokinetics, safety and clinical efficacy, monotherapy and combination therapy strategies, and clinical challenges associated with histone deacetylase inhibitors in leukemia treatment, along with the latest evidence and ongoing studies in the field. In addition, we discuss future directions to optimize the therapeutic potential of these agents.

Tumor Biology Hides Novel Therapeutic Approaches to Diffuse Large B-Cell Lymphoma: A Narrative Review

Diffuse large B-cell lymphoma (DLBCL) is a malignancy of immense biological and clinical heterogeneity. Based on the transcriptomic or genomic approach, several different classification schemes have evolved over the years to subdivide DLBCL into clinically (prognostically) relevant subsets, but each leaves unclassified samples. Herein, we outline the DLBCL tumor biology behind the actual and potential drug targets and address the challenges and drawbacks coupled with their (potential) use. Therapeutic modalities are discussed, including small-molecule inhibitors, naked antibodies, antibody-drug conjugates, chimeric antigen receptors, bispecific antibodies and T-cell engagers, and immune checkpoint inhibitors. Candidate drugs explored in ongoing clinical trials are coupled with diverse toxicity issues and refractoriness to drugs. According to the literature on DLBCL, the promise for new therapeutic targets lies in epigenetic alterations, B-cell receptor and NF-κB pathways. Herein, we present putative targets hiding in lipid pathways, ferroptosis, and the gut microbiome that could be used in addition to immuno-chemotherapy to improve the general health status of DLBCL patients, thus increasing the chance of being cured. It may be time to devote more effort to exploring DLBCL metabolism to discover novel druggable targets. We also performed a bibliometric and knowledge-map analysis of the literature on DLBCL published from 2014-2023.

Recent Advances in the Molecular Biology of Chronic Lymphocytic Leukemia: How to Define Prognosis and Guide Treatment

Chronic Lymphocytic Leukemia (CLL) is the most frequent type of leukemia in Western countries. In recent years, there have been important advances in the knowledge of molecular alterations that underlie the disease's pathogenesis. Very heterogeneous prognostic subgroups have been identified by the mutational status of immunoglobulin heavy variable genes (IGVH), FISH analysis and molecular evaluation of TP53 mutations. Next-generation sequencing (NGS) technologies have provided a deeper characterization of the genomic and epigenomic landscape of CLL. New therapeutic targets have led to a progressive reduction of traditional chemoimmunotherapy in favor of specific biological agents. Furthermore, in the latest clinical trials, the minimal residual disease (MRD) has emerged as a potent marker of outcome and a guide to treatment duration. This review focuses on recent insights into the understanding of CLL biology. We also consider the translation of these findings into the development of risk-adapted and targeted therapeutic approaches.

BTK inhibitors: moving the needle on the treatment of chronic lymphocytic leukemia

INTRODUCTION

Bruton's tyrosine kinaseinhibitors (BTKis) changed the trajectory of upfront and relapsed/refractory chronic lymphocytic leukemia (CLL) treatment. However, BTKis are plagued by a spectrum of toxicities. Zanubrutinib was developed to circumvent challenges with prolonged tolerability by increasing BTK selectivity and maximizing efficacy through pharmacokinetic/pharmacodynamic optimization. However, with the availability of ibrutinib, acalabrutinib, and zanubrutinib, limited data exists to guide sequencing of BTKi therapy in the relapsed/refractory setting.

AREAS COVERED

We review the first head-to-head trial (ALPINE) of zanubrutinib versus ibrutinib for the treatment of relapsed/refractory CLL and compare zanubrutinib's clinical efficacy and toxicities, including in patients with del(17p) and/or TP53 mutations to ibrutinib and acalabrutinib.

EXPERT OPINION

Zanubrutinibrepresents one of the new standards of care for relapsed/refractory CLL based on superior progression-free survival and response rates over ibrutinib. Whilezanubrutinib is associated with fewer cardiac toxicities, similar rates of neutropenia and hypertension are noted. Ongoing studies are pushing the envelope, utilizing targeted drug combinations and minimal residual disease markers as well as receptor tyrosine kinase-like orphan receptor 1 inhibitors, chimeric antigen receptor T-cells, and novel BTK degraders. However, zanubrutinibrepresents a strong contender in the arsenal of treatment options for relapsed/refractory CLL.

Fixed-duration pirtobrutinib plus venetoclax with or without rituximab in relapsed/refractory CLL: the phase 1b BRUIN trial

ABSTRACT

Pirtobrutinib is a highly selective, noncovalent (reversible) Bruton tyrosine kinase inhibitor (BTKi). Patients with relapsed or refractory (R/R) chronic lymphocytic leukemia (CLL) were treated with fixed-duration pirtobrutinib plus venetoclax (PV) or pirtobrutinib plus venetoclax and rituximab (PVR) in this phase 1b trial. Prior covalent BTKi therapy was allowed, but not prior treatment with venetoclax. Patients were assigned to receive PV (n = 15) or PVR (n = 10) for 25 cycles. Most patients (68%) had received prior covalent BTKi therapy. At the data cutoff date, the median time on study was 27.0 months for PV and 23.3 months for PVR. Overall response rates were 93.3% (95% confidence interval [CI], 68.1-99.8) for PV and 100% (95% CI, 69.2-100.0) for PVR, with 10 complete responses (PV: 7; PVR: 3). After 12 cycles of treatment, 85.7% (95% CI, 57.2-98.2) of PV and 90.0% (95% CI, 55.5-99.7) of PVR patients achieved undetectable minimal residual disease (<10-4) in peripheral blood. Progression-free survival at 18 months was 92.9% (95% CI, 59.1-99.0) for PV patients and 80.0% (95% CI, 40.9-94.6) for PVR patients. No dose-limiting toxicities were observed during the 5-week assessment period. The most common grade ≥3 adverse events (AEs) for all patients included neutropenia (52%) and anemia (16%). AEs led to dose reduction in 3 patients and discontinuation in 2. In conclusion, fixed-duration PV or PVR was well tolerated and had promising efficacy in patients with R/R CLL, including patients previously treated with a covalent BTKi. This trial was registered at www.clinicaltrials.gov as #NCT03740529.

Real-World Treatment Patterns and Outcomes by Line of Therapy and Race in Patients With Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Treated in the United States: Results From the Final Analysis of the Prospective, Observational, informCLL Registry

BACKGROUND

informCLL is the largest US-based prospective, observational registry of patients with chronic lymphocytic leukemia (CLL) initiating FDA-approved treatment in the era of targeted therapy.

PATIENTS AND METHODS

Patients were enrolled between October 2015 and June 2019. Data were collected for baseline characteristics, treatment patterns, outcomes, and safety.

RESULTS

In total, 1459 eligible patients were enrolled (first line, n = 854; relapsed/refractory, n = 605). The most common index treatments were ibrutinib (first line, 45%; relapsed/refractory, 49%) and chemoimmunotherapy (first line, 43%; relapsed/refractory, 20%). With median follow-up of 31.8 and 30.9 months in first-line and relapsed/refractory cohorts, respectively, median time to next treatment (TTNT) in patients who received any index treatment was not reached (NR) and 48.6 months; estimated proportions without next-line therapy at 48 months were 64% and 50%. Median overall survival (OS) was NR for both cohorts; estimated 48-month OS rates were 81% and 64% in first-line and relapsed/refractory cohorts, respectively. In match-adjusted analyses, TTNT was improved with first-line ibrutinib versus chemoimmunotherapy (median NR vs. 56.5 months; hazard ratio, 0.74; 95% CI, 0.56-0.98). Exposure-adjusted rates of AEs leading to discontinuation and serious AEs were lower with ibrutinib versus chemoimmunotherapy. Estimated 36-month OS rates were similar in Black versus White patients who received any index treatment (first line, 87% vs. 83%; relapsed/refractory, 74% vs. 74%) or ibrutinib (first line, 97% vs. 85%; relapsed/refractory, 81% vs. 77%).

CONCLUSION

In this prospective, large, real-world CLL registry, first-line ibrutinib was associated with longer TTNT than chemoimmunotherapy, with sustained benefit up to 4 years of follow-up.

Safety profile of first-line targeted therapies in elderly and/or comorbid chronic lymphocytic leukaemia patients (unfit subpopulation). A systematic review and network meta-analysis

This systematic literature review (CRD42023393903) and a Bayesian network meta-analysis (NMA) aimed to assess the relative safety profile of first-line targeted therapies (acalabrutinib, ibrutinib, obinutuzumab, ofatumumab, pirtobrutinib, ublituximab, umbralisib, venetoclax, zanubrutinib) in chronic lymphocytic leukaemia (CLL) patients with advanced age and/or comorbidities. The NMA revealed that zanubrutinib was the safest treatment option in terms of the overall safety profile (e.g., serious adverse events [AEs] grade 1-5), followed by venetoclax-obinutuzumab, which showed an advantage in terms of AEs grade 1-5. The use of Bruton's tyrosine kinase inhibitor (BTKi) monotherapy was more favourable in terms of the risk of haematological AEs, but chemoimmunotherapy showed advantages in terms of cardiovascular, gastrointestinal, and infectious AEs. The risk of secondary cancers was similar between treatments. In conclusion, targeted therapies are associated with variable and clinically relevant AEs. The therapies appear to be safer when used as monotherapy rather than in combination with immunological agents in naïve CLL patients with advanced age and/or comorbidities.

Pharmacological management of chronic lymphocytic leukemia: current and emerging therapies

INTRODUCTION

Chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL), characterized by its monoclonal lymphoproliferative nature, is an indolent but incurable malignancy. The treatment landscape of CLL/SLL has drastically transformed in the last decade since the introduction of targeted therapy and immune-effector T-cell therapy. The paradigm shift from chemoimmunotherapy to targeted and cellular therapies was largely driven by improved efficacy and safety. With the success of targeted therapies, novel agents and combinations are rapidly emerging on the horizon.

AREAS COVERED

In this review, we will summarize clinical evidence supporting current and emerging therapies with emphasis on investigational therapies and novel combinations of commercial agents. Clinical trials were identified via clinicaltrials.gov, and a PubMed literature search was last performed in June 2024.

EXPERT OPINION

With the availability of more effective and better-tolerated treatments for CLL/SLL, the role of early intervention should be further investigated due to its potential to alter disease course, delay progression, and improve overall survival rates. With many highly effective agents and combinations expected to become commercially available, attention to safety profiles and careful selection of patients for each treatment will be critical, with consideration of comorbidities, logistical issues, and financial burden of treatment.

Dysregulated MicroRNAs in Chronic Lymphocytic Leukemia

MiRNAs are a class of non-coding RNAs acting as gene expression regulators by modulating the lifespan of messenger RNA. Commonly referred to as the most frequent leukemia in the Western world, chronic lymphocytic leukemia (CLL) is a lymphoproliferative malignancy characterized by clonal expansion of CD19, CD23, and CD5-positive mature B-cells. While this pathology is regarded as less aggressive and has a variety of treatment options, the cause of its clinical heterogeneity is not yet understood. Moreover, the prognostic markers and treatment recommendations based on predictive markers are limited. This review aims to investigate some miRNAs that are dysregulated and possibly involved in CLL pathogenesis as a starting point for the proposal of new prognostic and predictive markers and, as more agents targeting miRNA expression become available, their potential role as therapeutic targets.

Focal adhesion kinase as a new player in the biology of onco-hematological diseases: the starting evidence

Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase mainly found in the focal adhesion regions of the plasma membrane and it has a crucial role in migration and the remodeling of cellular morphology. FAK is also linked to several aspects of cancer biology, from cytokine production to angiogenesis, drug resistance, invasion, and metastasis, as well as epithelial-to-mesenchymal transition. The gene locus of FAK is frequently amplified in several human tumors, thus causing FAK overexpression in several cancers. Furthermore, FAK can influence extracellular matrix production and exosome secretion through cancer-associated fibroblasts, thus it has an important role in tumor microenvironment regulation. Although the role of FAK in solid tumors is well known, its importance in onco-hematological diseases remains poorly explored. This review collects studies related to FAK significance in onco-hematological diseases and their microenvironments. Overall, the importance of FAK in blood tumors is increasingly evident, but further research is required to confirm it as a new therapeutic target in hematological contexts.

Tuning the B-CLL microenvironment: evidence for BAG3 protein- mediated regulation of stromal fibroblasts activity

The Bcl2-associated athanogene-3 (BAG3) protein, a critical regulator of cellular survival, has been identified as a potential therapeutic target in various malignancies. This study investigates the role of BAG3 within stromal fibroblasts and its interaction with B-cell chronic lymphocytic leukemia (B-CLL) cells. Previous research demonstrated that BAG3 maintains the active state of pancreatic stellate cells (PSCs) and aids pancreatic ductal adenocarcinoma (PDAC) spread via cytokine release. To explore BAG3's role in bone marrow-derived stromal fibroblasts, BAG3 was silenced in HS-5 cells using siRNA. In co-culture experiments with PBMCs from B-CLL patients, BAG3 silencing in HS-5 cells increased apoptosis and decreased phosphorylation of BTK, AKT, and ERK in B-CLL cells, thus disrupting their pro-survival key signaling pathways. The observation of fibroblast-activated protein (FAP) positive cells in infiltrated bone marrow specimens co-expressing BAG3 further support the involvement of the protein in fibroblast-mediated tumor survival. Additionally, BAG3 appears to support B-CLL survival by modulating cytokine networks, including IL-10 and CXCL12, which are essential for leukemic cell survival and proliferation. A robust correlation between BAG3 expression and the levels of CXCL12 and IL-10 was observed in both co-cultures and patient specimens. These findings point out the need for a more in-depth comprehension of the intricate network of interactions within the tumor microenvironment and provide valuable insights for the selection of new potential therapeutic targets in the medical treatment of CLL.

Synthesis and Biochemical Evaluation of Ethanoanthracenes and Related Compounds: Antiproliferative and Pro-Apoptotic Effects in Chronic Lymphocytic Leukemia (CLL)

Chronic lymphocytic leukemia (CLL) is a malignancy of mature B cells, and it is the most frequent form of leukemia diagnosed in Western countries. It is characterized by the proliferation and accumulation of neoplastic B lymphocytes in the blood, lymph nodes, bone marrow and spleen. We report the synthesis and antiproliferative effects of a series of novel ethanoanthracene compounds in CLL cell lines. Structural modifications were achieved via the Diels-Alder reaction of 9-(2-nitrovinyl)anthracene and 3-(anthracen-9-yl)-1-arylprop-2-en-1-ones (anthracene chalcones) with dienophiles, including maleic anhydride and N-substituted maleimides, to afford a series of 9-(E)-(2-nitrovinyl)-9,10-dihydro-9,10-[3,4]epipyrroloanthracene-12,14-diones, 9-(E)-3-oxo-3-phenylprop-1-en-1-yl)-9,10-dihydro-9,10-[3,4]epipyrroloanthracene-12,14-diones and related compounds. Single-crystal X-ray analysis confirmed the structures of the novel ethanoanthracenes 23f, 23h, 24a, 24g, 25f and 27. The products were evaluated in HG-3 and PGA-1 CLL cell lines (representative of poor and good patient prognosis, respectively). The most potent compounds were identified as 20a, 20f, 23a and 25n with IC50 values in the ranges of 0.17-2.69 µM (HG-3) and 0.35-1.97 µM (PGA-1). The pro-apoptotic effects of the potent compounds 20a, 20f, 23a and 25n were demonstrated in CLL cell lines HG-3 (82-95%) and PGA-1 (87-97%) at 10 µM, with low toxicity (12-16%) observed in healthy-donor peripheral blood mononuclear cells (PBMCs) at concentrations representative of the compounds IC50 values for both the HG-3 and PGA-1 CLL cell lines. The antiproliferative effect of the selected compounds, 20a, 20f, 23a and 25n, was mediated through ROS flux with a marked increase in cell viability upon pretreatment with the antioxidant NAC. 25n also demonstrated sub-micromolar activity in the NCI 60 cancer cell line panel, with a mean GI50 value of 0.245 µM. This ethanoanthracene series of compounds offers potential for the further development of lead structures as novel chemotherapeutics to target CLL.