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Mauro FR, Frustaci AM, Visentin A, Vitale C, Bartoletti M, Oltolini C, Zappulo E, Mikulska M. Severe infections in patients with chronic lymphocytic leukemia included in trials investigating BTK and BCL2 inhibitors. Crit Rev Oncol Hematol 2024:104408. [PMID: 38880368 DOI: 10.1016/j.critrevonc.2024.104408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/30/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL-2 inhibitor venetoclax have significantly improved the prognosis of patients with chronic lymphocytic leukemia (CLL). However, the incidence of severe infections in patients receiving these agents needs to be better understood. Our review aimed to provide an overview of grade ≥3 infections in patients with CLL who received BTKi and venetoclax-based therapy in prospective trials. Infection rates were influenced by the age of patients and the duration of follow-up. For treatment-naive (TN) patients receiving BTKi, infection rates ranged between 11.4% and 27.4% and were close to 30% in relapsed/refractory (R/R) patients. TN and R/R patients receiving fixed-duration venetoclax-based treatments showed variable rates, with maximum values around 20%. Opportunistic and fatal infections were uncommon. In conclusion, infections remain a concern in patients with CLL receiving targeted agents. A better definition of factors increasing infection vulnerability could help identify those patients who require infection prophylaxis.
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Affiliation(s)
- Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele Milan, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery University of Naples Federico II, Napoli Italy
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL) University of Genoa, Italy; Infectious Diseases Unit IRCCS Ospedale Policlinico San Martino Genoa, Italy
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2
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Cheson BD, Sharman JP. Current Approaches and Novel New Agents in the Treatment of Chronic Lymphocytic Leukemia. JCO Oncol Pract 2024:OP2300770. [PMID: 38848511 DOI: 10.1200/op.23.00770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/04/2024] [Accepted: 04/16/2024] [Indexed: 06/09/2024] Open
Abstract
The treatment of CLL has evolved from traditional chemoimmunotherapy (CIT) to an increasing number of targeted and biologic approaches. Randomized trials have demonstrated superiority of covalent bruton tyrosine kinase inhibitors (cBTKis) over CIT, and second-generation compounds such as acalabrutinib and zanubrutinib appear to have a more favorable efficacy/safety profile than ibrutinib. The noncovalent BTKi, pirtobrutinib, has shown impressive activity after failure of the cBTKis and is quite tolerable. The Bcl-2 inhibitor venetoclax plus a CD20, generally obinutuzumab, provides a high level of efficacy as initial treatment or after failure on a cBTKi, with many patients achieving a state of undetectable minimal residual disease. Promising novel approaches include BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T)-cell therapy. What is clear is that CIT is archaic, and current and future targeted approaches will continue to improve the outcome for patients with chronic lymphocytic leukemia.
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Affiliation(s)
| | - Jeff P Sharman
- Willamette Valley Cancer Institute, Medical Director of Hematology Research: Sara Cannon, Eugene, OR
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3
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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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4
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Ahn IE, Davids MS. Therapeutic targeting of apoptosis in chronic lymphocytic leukemia. Semin Hematol 2024; 61:109-118. [PMID: 38538512 DOI: 10.1053/j.seminhematol.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 06/09/2024]
Abstract
Therapeutic targeting of apoptosis with small molecule B-cell lymphoma 2 (BCL-2) inhibition with venetoclax is highly efficacious in CLL, leading to sustained deep responses, particularly among patients with treatment-naïve disease with favorable prognostic markers. Patients with unfavorable genetic characteristics such as TP53 aberration and unmutated IGHV may also derive durable benefits, but their remission duration after time-limited venetoclax-containing combination therapy is shorter, particularly in patients with relapsed/refractory disease. Emerging data indicate that the context of disease progression after initial treatment with venetoclax may define the success of re-treatment with venetoclax. Specifically, continuous venetoclax exposure may select for resistant disease due to genetic mechanisms such as BCL2 mutations and functional resistance mechanisms such as hyperphosphorylation of BCL-2 family proteins, which decrease the affinity of venetoclax binding to the target or lead to increased MCL-1 dependence and concomitant decrease in BCL-2 dependence. These patients may be best served by switching to a different class of targeted agents at the time of progression. In contrast, relapsed CLL that arises while being off therapy after a period of time-limited venetoclax-based regimens maintains sensitivity to re-treatment with venetoclax for the majority of patients. Novel strategies related to therapeutic targeting of apoptosis include next-generation BCL-2 inhibitors with improved potency and pharmacokinetic profiles, direct targeting of anti-apoptotic BH3 family proteins beyond BCL-2 such as MCL-1, and indirect targeting of MCL-1 through mechanisms such as small molecule cyclin-dependent kinase 9 inhibitors.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Apoptosis/drug effects
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Proto-Oncogene Proteins c-bcl-2/antagonists & inhibitors
- Proto-Oncogene Proteins c-bcl-2/metabolism
- Sulfonamides/therapeutic use
- Sulfonamides/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Molecular Targeted Therapy/methods
- Drug Resistance, Neoplasm/drug effects
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Affiliation(s)
- Inhye E Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
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5
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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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6
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Patton JT, Woyach JA. Targeting the B cell receptor signaling pathway in chronic lymphocytic leukemia. Semin Hematol 2024; 61:100-108. [PMID: 38749798 DOI: 10.1053/j.seminhematol.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/04/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024]
Abstract
Aberrant signal transduction through the B cell receptor (BCR) plays a critical role in the pathogenesis of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). BCR-dependent signaling is necessary for the growth and survival of neoplastic cells, making inhibition of down-stream pathways a logical therapeutic strategy. Indeed, selective inhibitors against Bruton's tyrosine kinase (BTK) and phosphoinositide 3-kinase (PI3K) have been shown to induce high rates of response in CLL and other B cell lymphomas. In particular, the development of BTK inhibitors revolutionized the treatment approach to CLL, demonstrating long-term efficacy. While BTK inhibitors are widely used for multiple lines of treatment, PI3K inhibitors are much less commonly utilized, mainly due to toxicities. CLL remains an incurable disease and effective treatment options after relapse or development of TKI resistance are greatly needed. This review provides an overview of BCR signaling, a summary of the current therapeutic landscape, and a discussion of the ongoing trials targeting BCR-associated kinases.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Signal Transduction/drug effects
- Receptors, Antigen, B-Cell/metabolism
- Receptors, Antigen, B-Cell/antagonists & inhibitors
- Protein Kinase Inhibitors/therapeutic use
- Protein Kinase Inhibitors/pharmacology
- Agammaglobulinaemia Tyrosine Kinase/antagonists & inhibitors
- Agammaglobulinaemia Tyrosine Kinase/metabolism
- Molecular Targeted Therapy
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents/pharmacology
- Phosphoinositide-3 Kinase Inhibitors/therapeutic use
- Phosphoinositide-3 Kinase Inhibitors/pharmacology
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Affiliation(s)
- John T Patton
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jennifer A Woyach
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH.
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7
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Visentin A, Frazzetto S, Trentin L, Chiarenza A. Innovative Combinations, Cellular Therapies and Bispecific Antibodies for Chronic Lymphocytic Leukemia: A Narrative Review. Cancers (Basel) 2024; 16:1290. [PMID: 38610967 PMCID: PMC11011076 DOI: 10.3390/cancers16071290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/14/2024] Open
Abstract
In the last few years, several agents targeting molecules that sustain the survival and the proliferation of chronic lymphocytic leukemia (CLL) cells have become clinically available. Most of these drugs target surface proteins, such as CD19 or CD20, via monoclonal or bispecific monoclonal antibodies (BsAbs), CAR T cells, intracellular proteins like BTK by using covalent or non-covalent inhibitors or BCL2 with first or second generation BH3-mimetics. Since the management of CLL is evolving quickly, in this review we highlighted the most important innovative treatments including novel double and triple combination therapies, CAR T cells and BsAbs for CLL. Recently, a large number of studies on novel combinations and newer strategic options for CLL therapy have been published or presented at international conferences, which were summarized and linked together. Although the management of treatment with a single continuous agent is easier, the emergence of protein mutations, long-term toxicities and costs are important concerns that favor the use of a fixed duration therapy. In the future, a measurable residual disease (MRD)-guided treatment cessation and MRD-based re-initiation of targeted therapy seems to be a more feasible approach, allowing identification of the patients who might benefit from continuous therapy or who might need a consolidation with BsAbs or CAR T cells to clear the neoplastic clone.
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Affiliation(s)
- Andrea Visentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Sara Frazzetto
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
| | - Livio Trentin
- Hematology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy;
| | - Annalisa Chiarenza
- Hematology and Stem Cell Transplantation Unit, A.O.U. Policlinico, 95123 Catania, Italy; (S.F.); (A.C.)
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8
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Ahn IE, Brander DM, Ren Y, Zhou Y, Tyekucheva S, Walker HA, Black R, Montegaard J, Alencar A, Shune L, Omaira M, Jacobson CA, Armand P, Ng SY, Crombie J, Fisher DC, LaCasce AS, Arnason J, Hochberg EP, Takvorian RW, Abramson JS, Brown JR, Davids MS. Five-year follow-up of a phase 2 study of ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial therapy in CLL. Blood Adv 2024; 8:832-841. [PMID: 38163317 PMCID: PMC10874751 DOI: 10.1182/bloodadvances.2023011574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT We previously reported high rates of undetectable minimal residual disease <10-4 (uMRD4) with ibrutinib plus fludarabine, cyclophosphamide, and rituximab (iFCR) followed by 2-year ibrutinib maintenance (I-M) in treatment-naïve chronic lymphocytic leukemia (CLL). Here, we report updated data from this phase 2 study with a median follow-up of 63 months. Of 85 patients enrolled, including 5 (6%) with deletion 17p or TP53 mutation, 91% completed iFCR and 2-year I-M. Five-year progression-free survival (PFS) and overall survival were 94% (95% confidence interval [CI], 89%-100%) and 99% (95% CI, 96%-100%), respectively. No additional deaths have occurred with this extended follow-up. No difference in PFS was observed by immunoglobulin heavy-chain variable region gene status or duration of I-M. High rates of peripheral blood (PB) uMRD4 were maintained (72% at the end of iFCR, 66% at the end of 2-year I-M, and 44% at 4.5 years from treatment initiation). Thirteen patients developed MRD conversion without clinical progression, mostly (77%) after stopping ibrutinib. None had Bruton tyrosine kinase (BTK) mutations. One patient had PLCG2 mutation. Six of these patients underwent ibrutinib retreatment per protocol. Median time on ibrutinib retreatment was 34 months. The cumulative incidence of atrial fibrillation was 8%. Second malignancy or nonmalignant hematologic disease occurred in 13%, mostly nonmelanoma skin cancer. Overall, iFCR with 2-year I-M achieved durably deep responses in patients with diverse CLL genetic markers. Re-emergent clones lacked BTK mutation and retained sensitivity to ibrutinib upon retreatment. This trial is registered at www.clinicaltrials.gov as #NCT02251548.
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Affiliation(s)
- Inhye E. Ahn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Heather A. Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Black
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alvaro Alencar
- Division of Hematology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL
| | - Leyla Shune
- Department of Hematologic Malignancies, University of Kansas Cancer Center, Westwood, KS
| | - Mohammad Omaira
- Department of Medical Oncology, West Michigan Cancer Center, Kalamazoo, MI
| | - Caron A. Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Samuel Y. Ng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - David C. Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Ann S. LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jon Arnason
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ephraim P. Hochberg
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Ronald W. Takvorian
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jeremy S. Abramson
- Harvard Medical School, Boston, MA
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
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9
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Castillo JJ, Branagan AR, Sermer D, Flynn CA, Meid K, Little M, Stockman K, White T, Canning A, Guerrera ML, Kofides A, Liu S, Liu X, Richardson K, Tsakmaklis N, Patterson CJ, Hunter ZR, Treon SP, Sarosiek S. Ibrutinib and venetoclax as primary therapy in symptomatic, treatment-naïve Waldenström macroglobulinemia. Blood 2024; 143:582-591. [PMID: 37971194 PMCID: PMC10873534 DOI: 10.1182/blood.2023022420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/29/2023] [Accepted: 10/07/2023] [Indexed: 11/19/2023] Open
Abstract
ABSTRACT Concurrent Bruton tyrosine kinase and BCL2 inhibition has not yet been investigated in Waldenström macroglobulinemia (WM). We performed an investigator-initiated trial of ibrutinib and venetoclax in symptomatic treatment-naïve patients with MYD88-mutated WM. Patients received ibrutinib 420 mg once daily (cycle 1), followed by a ramp-up of venetoclax to 400 mg daily (cycle 2). The combination was then administered for 22 additional 4-week cycles. The attainment of very good partial response (VGPR) was the primary end point. Forty-five patients were enrolled in this study. The median baseline characteristics were as follows: age 67 years, serum IgM 43 g/L, and hemoglobin 102 g/L. Seventeen patients (38%) carried CXCR4 mutations. Nineteen patients (42%) achieved VGPR. Grade 3 or higher adverse events included neutropenia (38%), mucositis (9%), and tumor lysis syndrome (7%). Atrial fibrillation occurred in 3 (9%), and ventricular arrhythmia in 4 (9%) patients that included 2 grade 5 events. With a median follow-up of 24.4 months, the 24-month progression-free survival (PFS) and overall survival (OS) rates were 76% and 96%, respectively, and were not impacted by CXCR4 mutations. The median time on therapy was 10.2 months, and the median time after the end of therapy (EOT) was 13.3 months. Eleven of the 12 progression events occurred after EOT, and the 12-month PFS rates after EOT were 79%; 93% if VGPR was attained, and 69% for other patients (P = .12). Ibrutinib and venetoclax induced high VGPR rates and durable responses after EOT, although they were associated with a higher-than-expected rate of ventricular arrhythmia in patients with WM, leading to early study treatment termination. This trial was registered at www.clinicaltrials.gov as #NCT04273139.
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Affiliation(s)
- Jorge J. Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Andrew R. Branagan
- Department of Medicine, Harvard Medical School, Boston, MA
- Center for Multiple Myeloma, Massachusetts General Hospital, Boston, MA
| | - David Sermer
- Department of Medicine, Harvard Medical School, Boston, MA
- Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Catherine A. Flynn
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Kirsten Meid
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Megan Little
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Katherine Stockman
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Timothy White
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Alexa Canning
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Maria L. Guerrera
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Amanda Kofides
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Shirong Liu
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Xia Liu
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Kris Richardson
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Nicholas Tsakmaklis
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | | | - Zachary R. Hunter
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Steven P. Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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10
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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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11
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Pagliaro L, Cerretani E, Vento F, Montanaro A, Moron Dalla Tor L, Simoncini E, Giaimo M, Gherli A, Zamponi R, Tartaglione I, Lorusso B, Scita M, Russo F, Sammarelli G, Todaro G, Silini EM, Rigolin GM, Quaini F, Cuneo A, Roti G. CAD204520 Targets NOTCH1 PEST Domain Mutations in Lymphoproliferative Disorders. Int J Mol Sci 2024; 25:766. [PMID: 38255842 PMCID: PMC10815907 DOI: 10.3390/ijms25020766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
NOTCH1 PEST domain mutations are often seen in hematopoietic malignancies, including T-cell acute lymphoblastic leukemia (T-ALL), chronic lymphocytic leukemia (CLL), splenic marginal zone lymphoma (SMZL), mantle cell lymphoma (MCL), and diffuse large B-cell lymphoma (DLBCL). These mutations play a key role in the development and progression of lymphoproliferative tumors by increasing the Notch signaling and, consequently, promoting cell proliferation, survival, migration, and suppressing apoptosis. There is currently no specific treatment available for cancers caused by NOTCH1 PEST domain mutations. However, several NOTCH1 inhibitors are in development. Among these, inhibition of the Sarco-endoplasmic Ca2+-ATPase (SERCA) showed a greater effect in NOTCH1-mutated tumors compared to the wild-type ones. One example is CAD204520, a benzimidazole derivative active in T-ALL cells harboring NOTCH1 mutations. In this study, we preclinically assessed the effect of CAD204520 in CLL and MCL models and showed that NOTCH1 PEST domain mutations sensitize cells to the anti-leukemic activity mediated by CAD204520. Additionally, we tested the potential of CAD204520 in combination with the current first-line treatment of CLL, venetoclax, and ibrutinib. CAD204520 enhanced the synergistic effect of this treatment regimen only in samples harboring the NOTCH1 PEST domain mutations, thus supporting a role for Notch inhibition in these tumors. In summary, our work provides strong support for the development of CAD204520 as a novel therapeutic approach also in chronic lymphoproliferative disorders carrying NOTCH1 PEST domain mutations, emerging as a promising molecule for combination treatment in this aggressive subset of patients.
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Affiliation(s)
- Luca Pagliaro
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Elisa Cerretani
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy; (M.S.); (G.M.R.); (A.C.)
| | - Federica Vento
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy; (M.S.); (G.M.R.); (A.C.)
| | - Anna Montanaro
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
| | - Lucas Moron Dalla Tor
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
| | - Elisa Simoncini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
| | - Mariateresa Giaimo
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Andrea Gherli
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Raffaella Zamponi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Isotta Tartaglione
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
| | - Bruno Lorusso
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
| | - Matteo Scita
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy; (M.S.); (G.M.R.); (A.C.)
| | - Filomena Russo
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Gabriella Sammarelli
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Giannalisa Todaro
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
| | - Enrico Maria Silini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
| | - Gian Matteo Rigolin
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy; (M.S.); (G.M.R.); (A.C.)
- Hematology Unit, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Federico Quaini
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
| | - Antonio Cuneo
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy; (M.S.); (G.M.R.); (A.C.)
- Hematology Unit, University Hospital of Ferrara, 44121 Ferrara, Italy
| | - Giovanni Roti
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (L.P.); (A.M.); (L.M.D.T.); (E.S.); (M.G.); (A.G.); (R.Z.); (B.L.); (E.M.S.); (F.Q.)
- Translational Hematology and Chemogenomics (THEC), University of Parma, 43126 Parma, Italy; (E.C.); (F.V.); (I.T.)
- Hematology and BMT Unit, University Hospital of Parma, 43126 Parma, Italy; (F.R.); (G.S.); (G.T.)
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12
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Rhodes JM. MRD-directed therapy in CLL: ready for prime time? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:413-420. [PMID: 38066928 PMCID: PMC10727082 DOI: 10.1182/hematology.2023000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
In recent years, the treatment paradigm for patients with chronic lymphocytic leukemia (CLL) has moved away from chemoimmunotherapy (CIT) toward the use of novel targeted agents. Commercially available drugs, including Bruton's tyrosine kinase inhibitors and the BCL2 inhibitor venetoclax, often used in combination with anti-CD20 monoclonal antibodies, are now the mainstay of therapy both in the frontline and in relapsed settings. As the landscape for CLL management evolves, therapeutic endpoints need to be redefined. Detection of measurable residual disease (MRD) is a sensitive tool to identify disease burden following treatment with several therapeutic regimens in CLL (including CIT, venetoclax-based regimens, and cellular therapies), and it has demonstrated prognostic value. Despite recent advances, the utility of MRD-directed therapy and attempts to eradicate it in routine clinical practice remain debated. There is little comparative data from clinical trials on the best assay to determine undetectable MRD (U-MRD) and whether its monitoring can lead to changes in treatment strategies. Our review discusses the definitions of MRD, assays for its detection, and its impact on long-term survival outcomes for patients with a CLL diagnosis.
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Affiliation(s)
- Joanna M. Rhodes
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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13
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Baratè C, Sanna A, Benedetti E, Bocchia M, Capochiani E, Danesi R, Moretti S, Occhini U, Santini S, Galimberti S, Gozzetti A. Real-life diagnostic and therapeutic approach to CLL: a 2022 update from an expert panel in Tuscany. Clin Exp Med 2023; 23:4251-4264. [PMID: 37979127 DOI: 10.1007/s10238-023-01244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
A panel of chronic lymphocytic leukemia (CLL) experts from Tuscany propose a real-life diagnostic and therapeutic approach CLL that considers the role of genomic and somatic prognostic factors in risk stratification and treatment decisions. Safety and efficacy of new agents has been demonstrated now not only in clinical trials but also in many real-world series. The BTK inhibitors, ibrutinib and acalabrutinib, and BH3 mimetic venetoclax are now indicated as first-line therapy and chemoimmunotherapy can be spared to the majority of CLL patients, thus preventing unnecessary hematological and non-hematological toxicity and second primary tumors. For treatment, FISH for 17 p and P53 mutational status are essential. IGHV mutation can be done at diagnosis or before treatment. Echography is the gold standard radiological investigation in CLL, at both diagnosis and response evaluation. Chemotherapy is virtually abandoned. Age, genetic risk, and patient comorbidities have to be carefully evaluated for treatment decision. With the availability of different drugs, there is a need for a uniform and shared approach in daily therapeutic choice. The proposed approach is based on current evidence and guidelines as well as results from clinical trials and daily clinical experience.
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Affiliation(s)
- Claudia Baratè
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Edoardo Benedetti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), Pisa, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Enrico Capochiani
- Hematology Unit, Department of Internal Medicine, Toscana Nord Ovest, Leghorn, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | | | | | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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14
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Kang S, Ahn IE. Prognostic Markers in the Era of Targeted Therapies. Acta Haematol 2023; 147:33-46. [PMID: 37703841 DOI: 10.1159/000533704] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/18/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Small molecules targeting Bruton's tyrosine kinase (BTK) and B-cell lymphoma-2 have become the standard of care for the treatment of chronic lymphocytic leukemia (CLL), replacing chemoimmunotherapy (CIT) in most clinical settings. Ongoing trials explore targeted combinations and minimal residual disease-driven treatment cessation. These dramatic shifts in the current and upcoming treatment landscape of CLL raise the need to reevaluate existing prognostic markers and develop novel ones. SUMMARY This review examines prognostic markers in CLL patients treated with standard and investigational targeted therapies. Specifically, initial treatment of TP53 aberrant patients with a BTK inhibitor can achieve 70% progression-free survival (PFS) at 5 years, outperforming the 15% 5-year PFS with a CIT regimen containing fludarabine, cyclophosphamide, and rituximab (FCR). The prognostic implications of the immunoglobulin heavy chain variable gene (IGHV) mutation status have also changed. Unmutated IGHV is associated with inferior PFS and overall survival after FCR and inferior PFS with fixed-duration therapy with venetoclax and anti-CD20 monoclonal antibody but not with continuous BTK inhibitor treatment. KEY MESSAGES (1) Genetic variables (e.g., TP53 aberration, IGHV mutation, complex karyotype) have a prognostic significance in CLL patients treated with targeted therapy. (2) Understanding the prognostic and predictive values of these markers is critical for the development of a risk-adapted treatment strategy in CLL.
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Affiliation(s)
- Sorang Kang
- College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Inhye E Ahn
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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15
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Michallet AS, Letestu R, Le Garff-Tavernier M, Campos L, Ticchioni M, Dilhuydy MS, Morisset S, Rouille V, Mahé B, Laribi K, Villemagne B, Ferrant E, Tournilhac O, Delmer A, Molina L, Leblond V, Tomowiak C, de Guibert S, Orsini-Piocelle F, Banos A, Carassou P, Cartron G, Fornecker LM, Ysebaert L, Dartigeas C, Truchan-Graczyk M, Vilque JP, Schleinitz TA, Cymbalista F, Leprêtre S, Lévy V, Nguyen-Khac F, Feugier P. A fixed-duration immunochemotherapy approach in CLL: 5.5-year results from the phase 2 ICLL-07 FILO trial. Blood Adv 2023; 7:3936-3945. [PMID: 37026799 PMCID: PMC10410135 DOI: 10.1182/bloodadvances.2022009594] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/08/2023] Open
Abstract
In previously untreated, medically fit patients with chronic lymphocytic leukemia (CLL), research is focused on developing fixed-duration strategies to improve long-term outcomes while sparing patients from serious toxicities. The ICLL-07 trial evaluated a fixed-duration (15-month) immunochemotherapy approach in which after obinutuzumab-ibrutinib induction for 9 months, patients (n = 10) in complete remission (CR) with bone marrow (BM) measurable residual disease (MRD) <0.01% continued only ibrutinib 420 mg/day for 6 additional months (I arm), whereas the majority (n = 115) received up to 4 cycles of fludarabine/cyclophosphamide-obinutuzumab 1000 mg alongside the ibrutinib (I-FCG arm). Primary analysis at month 16 showed that 84 of 135 (62.2%) patients enrolled achieved CR with a BM MRD <0.01%. Here, we report follow-up at median 63 months. Peripheral blood (PB) MRD was assessed 6 monthly beyond the end of treatment using a highly sensitive (10-6) flow cytometry technique. In the I-FCG arm, the PB MRD <0.01% rate (low-level positive <0.01% or undetectable with limit of detection ≤10-4) in evaluable patients was still 92.5% (74/80) at month 40 and 80.6% (50/62) at month 64. No differences in the PB MRD status were apparent per to the IGHV mutational status. In the overall population, 4-year progression-free and overall survival rates were 95.5% and 96.2%, respectively. Twelve deaths occurred overall. Fourteen serious adverse events occurred beyond the end of treatment. Thus, our fixed-duration immunochemotherapy approach produced deep and sustained PB MRD responses, high survival rates, and low long-term toxicity. A randomized trial is needed to compare our immunochemotherapy approach with a chemotherapy-free strategy. This trial was registered at www.clinicaltrials.gov as #NCT02666898.
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Affiliation(s)
| | - Rémi Letestu
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
| | | | - Lydia Campos
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
| | | | | | | | - Valérie Rouille
- Department of Hematology, CHU Montpellier, Montpellier, France
| | - Béatrice Mahé
- Department of Hematology, Nantes University Hospital, Nantes, France
| | - Kamel Laribi
- Department of Hematology, CH Le Mans, Le Mans, France
| | | | - Emmanuelle Ferrant
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
| | - Olivier Tournilhac
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
| | - Alain Delmer
- Department of Hematology, CHU Reims, Reims, France
| | - Lysiane Molina
- Department of Hematology, CHU Grenoble, La Tronche, France
| | - Véronique Leblond
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | | | | | | | - Anne Banos
- Department of Hematology, CH Côte Basque, Bayonne, France
| | | | - Guillaume Cartron
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
| | | | - Loic Ysebaert
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
| | | | | | - Jean-Pierre Vilque
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
| | | | | | - Stéphane Leprêtre
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
| | - Vincent Lévy
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
| | | | - Pierre Feugier
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
| | - French Innovative Leukemia Organization (FILO) CLL group
- Department of Hematology, Centre Léon Bérard, Lyon, France
- Hematology Laboratory, Avicenne Hospital, Hôpitaux universitaires Paris Seine Saint-Denis (HUPSSD), Assistance Publique–Hôpitaux de Paris (AP-HP), Bobigny, France
- Department of Hematology Biology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology Biology, Le Centre Hospitalier Universitaire (CHU) Saint Etienne, Saint Etienne, France
- Department of Immunology, CHU Nice, Nice, France
- Department of Hematology, CHU Bordeaux, Pessac, France
- Department of Hematology, CHU Montpellier, Montpellier, France
- Department of Hematology, Nantes University Hospital, Nantes, France
- Department of Hematology, CH Le Mans, Le Mans, France
- Department of Hematology, CHD Vendée, La Roche-sur-Yon, France
- Department of Hematology and Oncology, CH Lyon-Sud, Hospices Civils de Lyon, Université Claude Bernard, Pierre-Benite, Lyon, France
- Department of Hematology and Cellular Therapy, CHU Hotel Dieu Hématologie, Clermont-Ferrand, France
- Department of Hematology, CHU Reims, Reims, France
- Department of Hematology, CHU Grenoble, La Tronche, France
- Department of Hematology, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
- Department of Hematology, CHU Poitiers, Poitiers, France
- Department of Hematology, CHU Rennes, Rennes, France
- Hematology Service, CH Annecy, Annecy, France
- Department of Hematology, CH Côte Basque, Bayonne, France
- Department of Hematology, CH Metz, Metz, France
- Department of Hematology, Montpellier University Hospital, Montpelllier, France
- Department of Hematology, Strasbourg University Hospital, Strasbourg, France
- Institut Universitaire du Cancer Toulouse-Oncopole, Toulouse, France
- Department of Hematology, CHU Tours, Hôpital Bretonneau, Tours, France
- Department of Hematology, CHU Angers, Angers, France
- Institut d'Hématologie de Basse-Normandie, Centre François Baclesse, Caen, France
- Department of Hematology, Institut Paoli Calmettes, Marseille, Marseille France
- Department of Hematology, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Inserm U1245 and Department of Hematology, Centre Centre Henri-Becquerel and Normandie University UNIROUEN, Rouen, France
- Department of Clinical Research, Avicenne Hospital, HUPSSD, AP-HP, Bobigny, France
- Department of Hematology, Centre Hospitalier Régional Universitaire de Nancy, Hôpitaux de Brabois, Vandoeuvre-lès-Nancy, France
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16
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Allan JN, Flinn IW, Siddiqi T, Ghia P, Tam CS, Kipps TJ, Barr PM, Elinder Camburn A, Tedeschi A, Badoux XC, Jacobs R, Kuss BJ, Trentin L, Zhou C, Szoke A, Abbazio C, Wierda WG. Outcomes in Patients with High-Risk Features after Fixed-Duration Ibrutinib plus Venetoclax: Phase II CAPTIVATE Study in First-Line Chronic Lymphocytic Leukemia. Clin Cancer Res 2023; 29:2593-2601. [PMID: 37282671 PMCID: PMC10345960 DOI: 10.1158/1078-0432.ccr-22-2779] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/20/2022] [Accepted: 03/10/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE The CAPTIVATE study investigated first-line ibrutinib plus venetoclax for chronic lymphocytic leukemia in 2 cohorts: minimal residual disease (MRD)-guided randomized discontinuation (MRD cohort) and Fixed Duration (FD cohort). We report outcomes of fixed-duration ibrutinib plus venetoclax in patients with high-risk genomic features [del(17p), TP53 mutation, and/or unmutated immunoglobulin heavy chain (IGHV)] in CAPTIVATE. PATIENTS AND METHODS Patients received three cycles of ibrutinib 420 mg/day then 12 cycles of ibrutinib plus venetoclax (5-week ramp-up to 400 mg/day). FD cohort patients (n = 159) received no further treatment. Forty-three MRD cohort patients with confirmed undetectable MRD (uMRD) after 12 cycles of ibrutinib plus venetoclax received randomized placebo treatment. RESULTS Of 195 patients with known status of genomic risk features at baseline, 129 (66%) had ≥1 high-risk feature. Overall response rates were >95% regardless of high-risk features. In patients with and without high-risk features, respectively, complete response (CR) rates were 61% and 53%; best uMRD rates: 88% and 70% (peripheral blood) and 72% and 61% (bone marrow); 36-month progression-free survival (PFS) rates: 88% and 92%. In subsets with del(17p)/TP53 mutation (n = 29) and unmutated IGHV without del(17p)/TP53 mutation (n = 100), respectively, CR rates were 52% and 64%; uMRD rates: 83% and 90% (peripheral blood) and 45% and 80% (bone marrow); 36-month PFS rates: 81% and 90%. Thirty-six-month overall survival (OS) rates were >95% regardless of high-risk features. CONCLUSIONS Deep, durable responses and sustained PFS seen with fixed-duration ibrutinib plus venetoclax are maintained in patients with high-risk genomic features, with similar PFS and OS to those without high-risk features. See related commentary by Rogers, p. 2561.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Piperidines/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
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Affiliation(s)
| | - Ian W. Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, Tennessee
| | - Tanya Siddiqi
- City of Hope National Medical Center, Duarte, California
| | - Paolo Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| | - Constantine S. Tam
- Peter MacCallum Cancer Center and St. Vincent's Hospital and the University of Melbourne, Melbourne, Victoria, Australia
| | | | - Paul M. Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | | | | | | | - Ryan Jacobs
- Levine Cancer Institute, Charlotte, North Carolina
| | - Bryone J. Kuss
- Flinders University and Medical Centre, Bedford Park, South Australia, Australia
| | | | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | - Anita Szoke
- Pharmacyclics LLC, an AbbVie Company, South San Francisco, California
| | | | - William G. Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas
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17
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Bennett R, Anderson MA, Seymour JF. Unresolved questions in selection of therapies for treatment-naïve chronic lymphocytic leukemia. J Hematol Oncol 2023; 16:72. [PMID: 37422670 PMCID: PMC10329329 DOI: 10.1186/s13045-023-01469-7] [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: 05/09/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The treatment landscape for chronic lymphocytic leukemia (CLL) continues to undergo considerable evolution. Optimal selection of initial therapy from multiple effective options provides a major challenge for clinicians, who need to consider both disease and patient factors in conjunction with a view to sequencing available therapies in event of disease relapse. REVIEW We explore the most topical clinically relevant unresolved questions through discussion of important available pertinent literature and propose expert opinion based on these data. (1) Shrinking role of chemoimmunotherapy (CIT); while novel therapies are generally superior, we highlight the utility of FCR for IGHV-mutated CLL. (2) Choosing between inhibitors of Bruton's tyrosine kinase (BTKi); while efficacy between agents is likely similar there are important differences in toxicity profiles, including the incidence of cardiac arrhythmia and hypertension. (3) BTKi with or without anti-CD20 monoclonal antibodies (mAb); while obinutuzumab-acalabrutinib (AO) may confer superior progression-free survival to acalabrutinib (Acala), this is not true of rituximab (Ritux) to ibrutinib (Ib)-we highlight that potential for increased side effects should be carefully considered. (4) Continuous BTKi versus time-limited venetoclax-obinutuzumab (VenO); we propose that venetoclax (Ven)-based therapy is generally preferable to BTKi with exception of TP53 aberrant disease. (5) BTKi-Ven versus VenO as preferred time-limited therapy; we discuss comparable efficacies and the concerns about simultaneous 1L exposure to both BTKi and Ven drug classes. (6) Utility of triplet therapy (BTKi-Ven-antiCD20 mAb) versus VenO; similar rates of complete response are observed yet with greater potential for adverse events. (7) Optimal therapy for TP53 aberrant CLL; while limited data are available, there are likely effective novel therapy combinations for TP53 aberrant disease including BTKi, BTKi-Ven ± antiCD20 mAb. CONCLUSION Frontline therapy for CLL should be selected based on efficacy considering the patient specific biologic profile of their disease and potential toxicities, considering patient comorbidities and preferences. With the present paradigm of sequencing effective agents, 1L combinations of novel therapies should be used with caution in view of potential adverse events and theoretical resistance mechanism concerns in the absence of compelling randomized data to support augmented efficacy.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, 1G, Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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18
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Rios-Olais FA, Hilal T. Measurable Residual Disease in Chronic Lymphocytic Leukemia: Current Understanding and Evolving Role in Clinical Practice. Curr Treat Options Oncol 2023:10.1007/s11864-023-01103-1. [PMID: 37195588 DOI: 10.1007/s11864-023-01103-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
OPINION STATEMENT Treatment of chronic lymphocytic leukemia (CLL) has evolved dramatically during the last decade, from chemoimmunotherapy (CIT)-based therapies to newer B-cell receptor (BCR) signaling targeting agents, which are sometimes given as continuous schemes. Response to treatment was traditionally defined according to clinical variables designed to assign a response category. Interest in assessing for deeper responses in CLL by the means of measurable residual disease (MRD) testing has been the subject of research during the last several years. Analyses and sub-analyses of clinical trials have shown that achieving undetectable MRD (uMRD) in CLL is an important prognostic factor. In this review, we summarize the available evidence about MRD in CLL, from the various assays available for measurement, the compartment to test, the impact of reaching uMRD according to the treatment regimen, and the results of fixed duration treatment guided by MRD trials. Finally, we summarize how MRD can be incorporated in clinical practice and how it may guide fixed duration treatment in the future should evidence continue to accumulate in that direction.
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Affiliation(s)
| | - Talal Hilal
- Mayo Clinic, 5777 E. Mayo Boulevard, Phoenix, AZ, 85054, USA.
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19
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Thompson PA, Keating MJ, Ferrajoli A, Jain N, Peterson CB, Garg N, Wang SA, Jorgensen JL, Kadia TM, Bose P, Pemmaraju N, Short NJ, Wierda WG. Venetoclax consolidation in high-risk CLL treated with ibrutinib for ≥1 year achieves a high rate of undetectable MRD. Leukemia 2023:10.1038/s41375-023-01901-4. [PMID: 37138019 DOI: 10.1038/s41375-023-01901-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 05/05/2023]
Abstract
Patients receiving ibrutinib for CLL rarely achieve undetectable measurable residual disease (U-MRD), necessitating indefinite therapy, with cumulative risks of treatment discontinuation due to progression or adverse events. This study added venetoclax to ibrutinib for up to 2 years, in patients who had received ibrutinib for ≥12 months (mo) and had ≥1 high risk feature (TP53 mutation and/or deletion, ATM deletion, complex karyotype or persistently elevated β2-microglobulin). The primary endpoint was U-MRD with 10-4 sensitivity (U-MRD4) in bone marrow (BM) at 12mo. Forty-five patients were treated. On intention-to-treat analysis, 23/42 (55%) patients improved their response to CR (2 pts were in MRD + CR at venetoclax initiation). U-MRD4 at 12mo was 57%. 32/45 (71%) had U-MRD at the completion of venetoclax: 22/32 stopped ibrutinib; 10 continued ibrutinib. At a median of 41 months from venetoclax initiation, 5/45 patients have progressed; none have died from CLL or Richter Transformation. In 32 patients with BM U-MRD4, peripheral blood (PB) MRD4 was analyzed every 6 months; 10/32 have had PB MRD re-emergence at a median of 13 months post-venetoclax. In summary, the addition of venetoclax in patients treated with ≥12mo of ibrutinib achieved high rate of BM U-MRD4 and may achieve durable treatment-free remission.
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Affiliation(s)
- Philip A Thompson
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Michael J Keating
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Christine B Peterson
- Department of Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Naveen Garg
- Department of Body Imaging, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Sa A Wang
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
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20
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Lovell AR, Sawyers J, Bose P. An update on the efficacy of Venetoclax for chronic lymphocytic leukemia. Expert Opin Pharmacother 2023; 24:1307-1316. [PMID: 37226798 DOI: 10.1080/14656566.2023.2218545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The BCL2 inhibitor venetoclax has dramatically changed the treatment of chronic lymphocytic leukemia (CLL) and has introduced the concept of time-limited therapy with targeted agents. AREAS COVERED This review discusses the mechanism of action of venetoclax, adverse effects, and the clinical data with this agent as identified by a selective search of clinical trials in the PubMed database. Venetoclax is FDA-approved with anti-CD20 monoclonal antibodies; however, research is ongoing evaluating its efficacy when given in combination with other agents, such as the Bruton's Tyrosine Kinase (BTK) inhibitors. EXPERT OPINION Venetoclax-based therapy is an excellent treatment option for patients interested in time-limited therapy and can be offered in both the front-line and relapsed/refractory settings. Tumor lysis syndrome (TLS) risk evaluation, preventative measures, and strict monitoring should be conducted, while these patients ramp up to target dose. Venetoclax-based therapies produce deep and durable responses with patients often achieving undetectable measurable residual disease (uMRD). This has led to a discussion of MRD-driven, finite-duration treatment approaches, although longer term data is still needed. While many patients eventually lose uMRD status, re-treatment with venetoclax remains an area of interest with promising results. Mechanisms of resistance to venetoclax are being elucidated, and research is ongoing.
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Affiliation(s)
| | - Jacki Sawyers
- MD Anderson Cancer Center, Division of Pharmacy, Houston, TX, USA
| | - Prithviraj Bose
- MD Anderson Cancer Center, Department of Leukemia, Division of Cancer Medicine, Houston, TX, USA
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21
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Setiawan SA, Liu WZ, Weng PW, Lee CH, Yadav VK, Hardianti MS, Yeh CT, Chao TY. Synergistic disruption of BTK and BCL-2 causes apoptosis while inducing ferroptosis in double-hit lymphoma. Eur J Pharmacol 2023; 943:175526. [PMID: 36693553 DOI: 10.1016/j.ejphar.2023.175526] [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: 07/05/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Double-hit lymphoma (DHL) is an aggressive subset of Diffuse Large B-cell Lymphoma (DLBCL) with poor outcomes and without satisfying treatment options. BTK inhibitor monotherapy is ineffective to suppress aggressive lymphoma. Hence, combination with other potential agents is warranted. Here, we demonstrated the second generation of BTK inhibitor, zanubrutinib, and a BCL-2 inhibitor, navitoclax, worked in synergistic manner to suppress DHL. Comprehensive in silico approach by interrogating single-cell to bulk-level profiling was employed along with in vitro and in vivo validation in DHL cell lines. Ablation of BTK enhanced sensitivity to navitoclax and suppressed proliferation of DHL cells. Combination of second generation of BTK inhibitor with navitoclax synergistically suppressed DLBCL cells with higher synergy score in DHL subset. The drug combination triggered apoptosis and ferroptosis, with the latter being characterized by reactive oxygen species (ROS) accumulation, extensive lipid peroxidation, and depletion of reduced glutathione. Moreover, ablation of BTK sensitized DHL cells to ferroptosis. Mechanistically, disruption of BTK and BCL-2 triggered ferroptosis by downregulating NRF2 and HMOX1, while deactivating GPX4. Combination of zanubrutinib and navitoclax effectively suppressed tumor growth in vivo. Our data suggest that zanubrutinib and navitoclax synergistically suppressed DHL by inducing apoptosis and ferroptosis.
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Affiliation(s)
- Syahru Agung Setiawan
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei City, 11031, Taiwan
| | | | - Pei-Wei Weng
- Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 11031, Taiwan; Department of Orthopaedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, 23561, Taiwan; Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, 11031, Taiwan
| | - Chia-Hwa Lee
- School of Medical Laboratory Science and Biotechnology, College of Medical Science and Technology, Taipei Medical University, Taipei, 110, Taiwan
| | - Vijesh Kumar Yadav
- Department of Medical Research & Education, Taipei Medical University-Shuang Ho Hospital, New Taipei City, 23561, Taiwan
| | - Mardiah Suci Hardianti
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Chi-Tai Yeh
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei City, 11031, Taiwan; Department of Medical Research & Education, Taipei Medical University-Shuang Ho Hospital, New Taipei City, 23561, Taiwan; Continuing Education Program of Food Biotechnology Applications, College of Science and Engineering, National Taitung University, Taitung, 95092, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, 11031, Taiwan.
| | - Tsu-Yi Chao
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei City, 11031, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei City, 11031, Taiwan; Department of Hematology & Oncology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, 23561, Taiwan; Division of Medical Oncology and Hematology, Tri-Service General Hospital, National Defense Medical Centre, Taipei, 11409, Taiwan.
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22
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Ryan CE, Brander DM, Barr PM, Tyekucheva S, Hackett LR, Collins MC, Fernandes SM, Ren Y, Zhou Y, McDonough MM, Walker HA, McEwan MR, Abramson JS, Jacobsen ED, LaCasce AS, Fisher DC, Brown JR, Davids MS. A phase 1b study of ibrutinib in combination with obinutuzumab in patients with relapsed or refractory chronic lymphocytic leukemia. Leukemia 2023; 37:835-842. [PMID: 36717653 DOI: 10.1038/s41375-023-01830-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
This study investigated ibrutinib plus obinutuzumab in relapsed/refractory CLL, evaluating tolerability of 3 sequencing regimens as well as overall safety and efficacy. Fifty-two patients were initially randomized 1:1:1 to receive either obinutuzumab 1 month before ibrutinib initiation, ibrutinib 1 month prior to obinutuzumab initiation, or to start both drugs concomitantly. Higher rates of infusion-related reactions were observed with the first sequence, and only the latter 2 cohorts were expanded. Grade 4 hematologic toxicity was uncommon, and notable all-grade non-hematologic toxicities included bruising (58%), hypertension (46%), arthralgia (38%), diarrhea (37%), transaminitis (35%), atrial fibrillation (21%), and serious infection (17%). Best overall response rate was 96% (including 40% CR and 56% PR). Best rates of undetectable minimal residual disease in peripheral blood and bone marrow were 27% and 19%, respectively. With a median follow-up of 41.5 months, four-year progression-free and overall survival rates are 74% and 93%, respectively. Correlative studies demonstrated that serum CCL4 and CXCL13 levels were associated with clinical response, and BH3 profiling revealed increased BCL-2 and BCL-xL dependence in CLL cells from patients on treatment. Overall, ibrutinib plus obinutuzumab was highly active, with a manageable safety profile, supporting further investigation of this type of approach in relapsed/refractory CLL.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Durham, NC, USA
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Liam R Hackett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary C Collins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stacey M Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mikaela M McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heather A Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Monica R McEwan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital, Boston, MA, USA
| | - Eric D Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann S LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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23
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Lipsky AH, Lamanna N. Novel combination approaches with targeted agents in frontline chronic lymphocytic leukemia. Cancer 2023; 129:18-31. [PMID: 36326285 DOI: 10.1002/cncr.34510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/06/2022]
Abstract
Targeted therapies have revolutionized the frontline treatment landscape for patients with chronic lymphocytic leukemia (CLL) and have largely displaced a reliance on chemoimmunotherapy when treating this disease. Multiple randomized trials have documented the efficacy of oral therapy with the Bruton tyrosine kinase inhibitors ibrutinib and acalabrutinib (and zanubrutinib, pending a supplemental new drug application in CLL), as well as BCL2 inhibition using venetoclax. In this review, the authors highlight novel therapeutic strategies for using these agents in combination, either as doublet therapy or as triplet therapy, with anti-CD20 antibodies. First, the current treatment landscape is outlined, and the data are reviewed for continuous and time-limited therapeutic approaches, which constitute the current standard of care. Then, more recent reports are described from phase 2 and 3 studies exploring different combination strategies of Bruton tyrosine kinase and BCL2 inhibition for treatment-naive patients. In addition, relevant differences are emphasized between patient characteristics (e.g., patient fitness and the presence of high-risk disease features) and study methodology (e.g., dosing schedule, randomization, and assessment of measurable residual disease) across trials. Finally, the authors revisit the currently available data for these approaches in the context of ongoing studies and future planned trials, evaluating their potential impact on the frontline treatment landscape for CLL in the years to come.
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Affiliation(s)
- Andrew H Lipsky
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York, USA
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, New York, USA
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24
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Ravandi F, Kreitman RJ, Tiacci E, Andritsos L, Banerji V, Barrientos JC, Bhat SA, Blachly JS, Broccoli A, Call T, Chihara D, Dearden C, Demeter J, Dietrich S, Else M, Epperla N, Falini B, Forconi F, Gladstone DE, Gozzetti A, Iyengar S, Johnston JB, Jorgensen J, Juliusson G, Lauria F, Lozanski G, Parikh SA, Park JH, Polliack A, Quest G, Robak T, Rogers KA, Saven A, Seymour JF, Tadmor T, Tallman MS, Tam CS, Thompson PA, Troussard X, Zent CS, Zenz T, Zinzani PL, Wörmann B, Rai K, Grever M. Consensus opinion from an international group of experts on measurable residual disease in hairy cell leukemia. Blood Cancer J 2022; 12:165. [PMID: 36509740 PMCID: PMC9744664 DOI: 10.1038/s41408-022-00760-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
A significant body of literature has been generated related to the detection of measurable residual disease (MRD) at the time of achieving complete remission (CR) in patients with hairy cell leukemia (HCL). However, due to the indolent nature of the disease as well as reports suggesting long-term survival in patients treated with a single course of a nucleoside analog albeit without evidence of cure, the merits of detection of MRD and attempts to eradicate it have been debated. Studies utilizing novel strategies in the relapse setting have demonstrated the utility of achieving CR with undetectable MRD (uMRD) in prolonging the duration of remission. Several assays including immunohistochemical analysis of bone marrow specimens, multi-parameter flow cytometry and molecular assays to detect the mutant BRAF V600E gene or the consensus primer for the immunoglobulin heavy chain gene (IGH) rearrangement have been utilized with few comparative studies. Here we provide a consensus report on the available data, the potential merits of MRD assessment in the front-line and relapse settings and recommendations on future role of MRD assessment in HCL.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Robert J Kreitman
- Laboratory of Molecular Biology, National Cancer Institute, NIH, Bethesda, MD, USA
| | - Enrico Tiacci
- Institute of Hematology, Department of Medicine and Surgery, University and Hospital of Perugia, Perugia, Italy
| | - Leslie Andritsos
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM, USA
| | - Versha Banerji
- Department of Internal Medicine & Biochemistry and Medical Genetics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- CancerCare Manitoba Research Institute, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Jacqueline C Barrientos
- Feinstein Institutes for Medical Research and Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Seema A Bhat
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - James S Blachly
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Alessandro Broccoli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli"; and Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Timothy Call
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Dai Chihara
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Judit Demeter
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Sasha Dietrich
- Department of Hematology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Monica Else
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Narendranath Epperla
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Brunangelo Falini
- Institute of Hematology, Department of Medicine and Surgery, University and Hospital of Perugia, Perugia, Italy
| | - Francesco Forconi
- School of Cancer Sciences, Cancer Research UK Southampton Centre, Faculty of Medicine, University of Southampton, Southampton, UK
- Haematology Department, Cancer Care Directorate, University Hospital Southampton NHS Trust, Southampton, UK
| | | | - Alessandro Gozzetti
- Dept. of Medicine, Surgery and Neurosciences, University of Siena, Policlinico S. Maria alle Scotte-, Siena, Italy
| | | | - James B Johnston
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jeffrey Jorgensen
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Gerard Lozanski
- Department of Pathology, The Ohio State University Medical Center, Columbus, OH, USA
| | | | - Jae H Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Alan Saven
- Division of Hematology and Oncology, Scripps Clinic, La Jolla, CA, USA
| | - John F Seymour
- Haematology Department, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Tamar Tadmor
- Hematology Unit, Bnai Zion Medical Center; and the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Martin S Tallman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Constantine S Tam
- Department of Haematology, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Philip A Thompson
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xavier Troussard
- Department of Hematology, Centre Hospitalier Universitaire Cote de Nacre, Caen, France
| | - Clive S Zent
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Thorsten Zenz
- Dept. of Medical Oncology and Haematology, University Hospital Zürich and University of Zurich (UZH), Zurich, Switzerland
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli"; and Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | | | - Kanti Rai
- Feinstein Institutes for Medical Research and Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Michael Grever
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
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25
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Selecting initial therapy in CLL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:323-328. [PMID: 36485152 PMCID: PMC9820765 DOI: 10.1182/hematology.2022000343] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Targeted therapy is a powerful treatment option in chronic lymphocytic leukemia (CLL) that has outperformed conventional chemoimmunotherapy in most clinical settings. Except for selected young, fit patients with a mutated immunoglobulin heavy chain variable region gene, most patients benefit from targeted therapy with either a continuous BTK inhibitor or 1-year fixed-duration venetoclax-obinutuzumab as first-line treatment of CLL. Treatment selection is driven by patient-, treatment-, and disease-related factors, encompassing patient preference, concomitant medications, comorbidities, safety profile of the regimen, and TP53 aberration. Clinical trials are actively investigating the simultaneous inhibition of Bruton's tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL-2) proteins with or without a CD20 monoclonal antibody, which can achieve deep response in most patients (52%-89% undetectable minimal residual disease in bone marrow).
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26
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Minimal residual disease-driven treatment intensification with sequential addition of ibrutinib to venetoclax in R/R CLL. Blood 2022; 140:2348-2357. [PMID: 35921541 DOI: 10.1182/blood.2022016901] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/17/2022] [Indexed: 11/20/2022] Open
Abstract
Undetectable measurable residual disease (uMRD) is achievable in patients with chronic lymphocytic leukemia (CLL) with the BCL2-inhibitor venetoclax alone or combined with the Bruton's tyrosine kinase inhibitor ibrutinib. This phase 2, multicenter, MRD-driven study was designed to discontinue treatment upon reaching uMRD4 (<10-4) in patients with relapsed/refractory CLL receiving venetoclax monotherapy or after the addition of ibrutinib. Primary end point of the study was proportion of uMRD4 with venetoclax ± ibrutinib. Secondary end points were overall response rate, partial response, complete response, progression-free survival, duration of response, overall survival, and safety of venetoclax ± ibrutinib. Patients with uMRD4 at Cycle 12 Day 1 discontinued venetoclax. MRD+ patients added ibrutinib and continued both drugs up to Cycle 24 Day 28/uMRD4/progression/toxicity. After Cycle 24 Day 28, MRD+ patients continued ibrutinib. Thirty-eight patients (29% with TP53 aberrations; 79% with unmutated IGHV) started venetoclax. Overall response rate with venetoclax was 36 (95%) of 38 patients (20 complete; 16 partial response). Seventeen patients (45%) with uMRD4 at Cycle 12 Day 1 discontinued venetoclax. Nineteen (55%) MRD+ subjects added ibrutinib. After a median of 7 months (range, 3-10 months) of combined treatment, 16 (84%) of 19 achieved uMRD4, thus stopping both drugs. Two MRD+ patients at Cycle 24 Day 28 continued ibrutinib until progression/toxicity. After a median follow-up of 36.5 months, median progression-free survival was not reached; 10 patients progressed (4 restarted venetoclax, 3 without treatment need, 2 developed Richter transformation, and 1 dropped out). Seven (22%) of 32 patients remain uMRD4 after 3 years of follow-up. Neutropenia was the most frequent grade 3 to 4 adverse event; no grade 5 events occurred on study. This sequential MRD-guided approach led to uMRD4 in 33 (87%) of 38 patients, with venetoclax monotherapy or combined with ibrutinib, delivering treatment combination only in a fraction, and ultimately identifying the few patients benefiting from continuous therapy. This trial was registered at www.clinicaltrials.gov as # NCT04754035.
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Wierda WG, Kipps TJ, Al-Sawaf O, Chyla B, Biondo JML, Mun Y, Jiang Y, Seymour JF. Utility of measurable residual disease for predicting treatment outcomes with BCR- and BCL2-Targeted therapies in patients with CLL. Leuk Lymphoma 2022; 63:2765-2784. [PMID: 35983732 DOI: 10.1080/10428194.2022.2098291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inhibitors targeting B-cell receptor (BCR) signaling pathway proteins and B-cell lymphoma-2 (BCL2) in chronic lymphocytic leukemia (CLL) are recommended in the first-line and relapsed/refractory disease settings. Measurable residual disease (MRD) is an important prognostic tool in patients treated with the BCL2-targeted agent, venetoclax. We explored the relationship between MRD status and progression-free (PFS)/overall survival (OS) in patients with CLL, following treatment with novel BCR- and BCL2-targeted agents. Compared with chemoimmunotherapy, higher rates of undetectable (u)MRD were achieved with BCL2-targeted therapies; achieving uMRD status was associated with longer PFS and OS than MRD-positivity. Continuous treatment with BCR-targeted agents did not achieve uMRD status in many patients, and outcomes were not correlated with uMRD status. Future clinical trials of targeted treatment combinations could be designed to demonstrate uMRD as a treatment objective, and allow a response-driven, personalized strategy to optimize treatment and improve OS outcomes.
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Affiliation(s)
| | | | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne Aachen Cologne Bonn Düsseldorf, German CLL Study Group, University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Yong Mun
- Genentech, Inc., South San Francisco, CA, USA
| | | | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
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Alu A, Lei H, Han X, Wei Y, Wei X. BTK inhibitors in the treatment of hematological malignancies and inflammatory diseases: mechanisms and clinical studies. J Hematol Oncol 2022; 15:138. [PMID: 36183125 PMCID: PMC9526392 DOI: 10.1186/s13045-022-01353-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Bruton's tyrosine kinase (BTK) is an essential component of multiple signaling pathways that regulate B cell and myeloid cell proliferation, survival, and functions, making it a promising therapeutic target for various B cell malignancies and inflammatory diseases. Five small molecule inhibitors have shown remarkable efficacy and have been approved to treat different types of hematological cancers, including ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and orelabrutinib. The first-in-class agent, ibrutinib, has created a new era of chemotherapy-free treatment of B cell malignancies. Ibrutinib is so popular and became the fourth top-selling cancer drug worldwide in 2021. To reduce the off-target effects and overcome the acquired resistance of ibrutinib, significant efforts have been made in developing highly selective second- and third-generation BTK inhibitors and various combination approaches. Over the past few years, BTK inhibitors have also been repurposed for the treatment of inflammatory diseases. Promising data have been obtained from preclinical and early-phase clinical studies. In this review, we summarized current progress in applying BTK inhibitors in the treatment of hematological malignancies and inflammatory disorders, highlighting available results from clinical studies.
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Affiliation(s)
- Aqu Alu
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hong Lei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China.
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29
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Ryan CE, Davids MS, Hermann R, Shahkarami M, Biondo J, Abhyankar S, Alhasani H, Sharman JP, Mato AR, Roeker LE. MAJIC: a phase III trial of acalabrutinib + venetoclax versus venetoclax + obinutuzumab in previously untreated chronic lymphocytic leukemia or small lymphocytic lymphoma. Future Oncol 2022; 18:3689-3699. [PMID: 36102212 DOI: 10.2217/fon-2022-0456] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Here we describe the rationale and design of MAJIC, a phase III, prospective, multicenter, randomized trial comparing the combination of the BTK inhibitor acalabrutinib plus the BCL2 inhibitor venetoclax versus the combination of venetoclax plus obinutuzumab as frontline treatment for chronic lymphocytic leukemia or small lymphocytic lymphoma. In both treatment arms, disease response (assessed by International Workshop on Chronic Lymphocytic Leukemia criteria) and minimal residual disease will be used to guide therapy duration, with all patients ultimately discontinuing treatment after a maximum of 2 years. The primary end point is progression-free survival. Key secondary end points include rates of undetectable minimal residual disease, overall response and overall survival. This study will address key unanswered questions in frontline chronic lymphocytic leukemia/small lymphocytic lymphoma therapy by investigating the optimal duration of finite treatment and identifying the optimal venetoclax doublet regimen.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | | | | | | | - Jeff P Sharman
- Willamette Valley Cancer Institute & Research Center/US Oncology, Eugene, OR, USA
| | - Anthony R Mato
- CLL Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lindsey E Roeker
- CLL Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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30
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Murphy RL, Paramithiotis E, Sugden S, Chermak T, Lambert B, Montamat-Sicotte D, Mattison J, Steinhubl S. The need for more holistic immune profiling in next-generation SARS-CoV-2 vaccine trials. Front Immunol 2022; 13:923106. [PMID: 36211354 PMCID: PMC9533322 DOI: 10.3389/fimmu.2022.923106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
First-generation anit-SARS-CoV-2 vaccines were highly successful. They rapidly met an unforeseen emergency need, saved millions of lives, and simultaneously eased the burden on healthcare systems worldwide. The first-generation vaccines, however, focused too narrowly on antibody-based immunity as the sole marker of vaccine trial success, resulting in large knowledge gaps about waning vaccine protection, lack of vaccine robustness to viral mutation, and lack of efficacy in immunocompromised populations. Detailed reviews of first-generation vaccines, including their mode of action and geographical distribution, have been published elsewhere. Second-generation clinical trials must address these gaps by evaluating a broader range of immune markers, including those representing cell-mediated immunity, to ensure the most protective and long-lasting vaccines are brought to market.
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Affiliation(s)
- Robert L. Murphy
- Northwestern University, Evanston, IL, United States
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- *Correspondence: Robert L. Murphy,
| | | | | | | | - Bruce Lambert
- Northwestern University, Evanston, IL, United States
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31
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Lovell AR, Jammal N, Bose P. Selecting the optimal BTK inhibitor therapy in CLL: rationale and practical considerations. Ther Adv Hematol 2022; 13:20406207221116577. [PMID: 35966045 PMCID: PMC9373150 DOI: 10.1177/20406207221116577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) inhibitors have dramatically changed the treatment
of newly diagnosed and relapsed/refractory chronic lymphocytic leukemia (CLL).
Ibrutinib, acalabrutinib, and zanubrutinib are Food and Drug Administration
(FDA)-approved BTK inhibitors that have all demonstrated progression-free
survival (PFS) benefit compared with chemoimmunotherapy. The efficacy of these
agents compared to one another is under study; however, current data suggest
they provide similar efficacy. Selectivity for BTK confers different adverse
effect profiles, and longer follow-up and real-world use have characterized side
effects over time. The choice of BTK inhibitor is largely patient-specific, and
this review aims to highlight the differences among the agents and guide the
choice of BTK inhibitor in clinical practice.
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Affiliation(s)
- Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadya Jammal
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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Wierda WG. Ibrutinib Plus Venetoclax for First-Line Chronic Lymphocytic Leukemia Treatment. NEJM EVIDENCE 2022; 1:EVIDe2200093. [PMID: 38319264 DOI: 10.1056/evide2200093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Ibrutinib Plus Venetoclax for First-Line Chronic Lymphocytic Leukemia TreatmentSmall-molecule inhibitor targeted therapy for patients with chronic lymphocytic leukemia (CLL) began with ibrutinib, the oral covalent inhibitor of Bruton's tyrosine kinase (BTKi). Phase III clinical trials demonstrated improved progression-free survival with ibrutinib compared with current standard treatment for first-line1-4 and relapsed or refractory CLL.5 BTKi therapy is extremely effective at eliminating nodal disease and prevents progression, including for patients with high-risk del(17p)/mutated-TP53 CLL. Patients receive BTKi maintenance until progression or side effects become limiting.
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Affiliation(s)
- William G Wierda
- Division of Cancer Medicine, Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston
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33
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Kater AP, Owen C, Moreno C, Follows G, Munir T, Levin MD, Benjamini O, Janssens A, Osterborg A, Robak T, Simkovic M, Stevens D, Voloshin S, Vorobyev V, Ysebaert L, Qin R, Steele AJ, Schuier N, Baeten K, Caces DB, Niemann CU. Fixed-Duration Ibrutinib-Venetoclax in Patients with Chronic Lymphocytic Leukemia and Comorbidities. NEJM EVIDENCE 2022; 1:EVIDoa2200006. [PMID: 38319255 DOI: 10.1056/evidoa2200006] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND: GLOW is a phase 3 trial evaluating the efficacy and safety of ibrutinib-venetoclax in older patients and/or those with comorbidities with previously untreated chronic lymphocytic leukemia (CLL). METHODS: We randomly assigned (1:1) patients 65 years of age or older or those 18 to 64 years of age who also had a Cumulative Illness Rating Scale (CIRS) score greater than 6 (CIRS scores range from 0 to 56, with higher scores indicating more impaired function of organ systems) or creatinine clearance of less than 70 ml/min, to ibrutinib-venetoclax (3 cycles ibrutinib lead-in, then 12 cycles ibrutinib-venetoclax) or chlorambucil-obinutuzumab (6 cycles). The primary end point was progression-free survival (PFS) assessed by an independent review committee. Secondary end points included undetectable minimal residual disease (uMRD), response rates, and safety. RESULTS: This study enrolled 211 patients, with 106 randomly assigned to ibrutinib-venetoclax and 105 to chlorambucil-obinutuzumab. With a median follow-up of 27.7 months, there were 22 PFS events for ibrutinib-venetoclax and 67 events for chlorambucil-obinutuzumab. PFS was significantly longer for ibrutinib-venetoclax than for chlorambucil-obinutuzumab (hazard ratio, 0.216; 95% confidence interval [CI], 0.131 to 0.357; P<0.001). The improvement in PFS with ibrutinib-venetoclax was consistent across predefined subgroups, including patients 65 years of age or older or with a CIRS score greater than 6. The best uMRD rate in bone marrow by next-generation sequencing was significantly higher for ibrutinib-venetoclax (55.7%) than for chlorambucil-obinutuzumab (21.0%; P<0.001). The proportion of patients with sustained uMRD in peripheral blood from 3 to 12 months after end of treatment was 84.5% for ibrutinib-venetoclax and 29.3% for chlorambucil-obinutuzumab. Four patients treated with ibrutinib-venetoclax required subsequent therapy compared with 27 patients receiving chlorambucil-obinutuzumab (hazard ratio, 0.143; 95% CI, 0.050 to 0.410). Adverse events grade 3 or greater occurred for 80 (75.5%) and 73 (69.5%) patients receiving ibrutinib-venetoclax and chlorambucil-obinutuzumab, respectively, with neutropenia being most common in both arms (37 [34.9%] and 52 [49.5%]). There were 11 (10.4%) and 12 (11.4%) all-cause deaths in the ibrutinib-venetoclax and chlorambucil-obinutuzumab arms, respectively. CONCLUSIONS: Ibrutinib-venetoclax, an all-oral, once-daily, fixed-duration combination, demonstrated superior PFS and deeper and better sustained responses versus chlorambucil-obinutuzumab as first-line CLL treatment in older patients and/or those with comorbidities. (Funded by Janssen Research & Development, LLC, and Pharmacyclics; ClinicalTrials.gov number, NCT03462719.)
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Affiliation(s)
- Arnon P Kater
- Amsterdam University Medical Centers, Cancer Center Amsterdam, University of Amsterdam, on behalf of the HOVON CLL Working Group, Amsterdam
| | - Carolyn Owen
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona
| | | | | | | | | | - Ann Janssens
- Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | | | - Tadeusz Robak
- Medical University of Łódź, Copernicus Memorial Hospital, Łódź, Poland
| | - Martin Simkovic
- University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | | | - Sergey Voloshin
- Russian Scientific Research Institute of Hematology and Transfusiology, St. Petersburg, Russia
| | | | - Loic Ysebaert
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Rui Qin
- Janssen Research & Development, Raritan, NJ
| | | | | | - Kurt Baeten
- Janssen Research & Development, Beerse, Belgium
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34
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A CAPTIVATE-ing new regimen for CLL. Blood 2022; 139:3229-3230. [PMID: 35653166 DOI: 10.1182/blood.2022015963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/03/2022] [Indexed: 11/20/2022] Open
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35
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Tam CS, Allan JN, Siddiqi T, Kipps TJ, Jacobs R, Opat S, Barr PM, Tedeschi A, Trentin L, Bannerji R, Jackson S, Kuss BJ, Moreno C, Szafer-Glusman E, Russell K, Zhou C, Ninomoto J, Dean JP, Wierda WG, Ghia P. Fixed-duration ibrutinib plus venetoclax for first-line treatment of CLL: primary analysis of the CAPTIVATE FD cohort. Blood 2022; 139:3278-3289. [PMID: 35196370 PMCID: PMC11022982 DOI: 10.1182/blood.2021014488] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/11/2022] [Indexed: 11/20/2022] Open
Abstract
CAPTIVATE (NCT02910583) is an international phase 2 study in patients aged ≤70 years with previously untreated chronic lymphocytic leukemia (CLL). Results from the cohort investigating fixed-duration (FD) treatment with ibrutinib plus venetoclax are reported. Patients received 3 cycles of ibrutinib lead-in then 12 cycles of ibrutinib plus venetoclax (oral ibrutinib [420 mg/d]; oral venetoclax [5-week ramp-up to 400 mg/d]). The primary endpoint was complete response (CR) rate. Hypothesis testing was performed for patients without del(17p) with prespecified analyses in all treated patients. Secondary endpoints included undetectable minimal residual disease (uMRD) rates, progression-free survival (PFS), overall survival (OS), and safety. Of the 159 patients enrolled and treated, 136 were without del(17p). The median time on study was 27.9 months, and 92% of patients completed all planned treatment. The primary endpoint was met, with a CR rate of 56% (95% confidence interval [CI], 48-64) in patients without del(17p), significantly higher than the prespecified 37% minimum rate (P < .0001). In the all-treated population, CR rate was 55% (95% CI, 48-63); best uMRD rates were 77% (peripheral blood [PB]) and 60% (bone marrow [BM]); 24-month PFS and OS rates were 95% and 98%, respectively. At baseline, 21% of patients were in the high tumor burden category for tumor lysis syndrome (TLS) risk; after ibrutinib lead-in, only 1% remained in this category. The most common grade ≥3 adverse events (AEs) were neutropenia (33%) and hypertension (6%). First-line ibrutinib plus venetoclax represents the first all-oral, once-daily, chemotherapy-free FD regimen for patients with CLL. FD ibrutinib plus venetoclax achieved deep, durable responses and promising PFS, including in patients with high-risk features.
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Affiliation(s)
- Constantine S. Tam
- Peter MacCallum Cancer Center, Melbourne, VIC, Australia
- St. Vincent's Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | | | | | - Thomas J. Kipps
- Moores Cancer Center, University of California San Diego, San Diego, CA
| | | | | | - Paul M. Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | | | - Rajat Bannerji
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | | | - Bryone J. Kuss
- Flinders University and Medical Center, Bedford Park, SA, Australia
| | - Carol Moreno
- Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | | | | | - Cathy Zhou
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | - Joi Ninomoto
- Pharmacyclics LLC, an AbbVie Company, Sunnyvale, CA
| | | | - William G. Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Paolo Ghia
- Università Vita-Salute San Raffaele, Milan, Italy
- IRCCS Ospedale San Raffaele, Milan, Italy
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Chen R, Chen Y, Xiong P, Zheleva D, Blake D, Keating MJ, Wierda WG, Plunkett W. Cyclin-dependent kinase inhibitor fadraciclib (CYC065) depletes anti-apoptotic protein and synergizes with venetoclax in primary chronic lymphocytic leukemia cells. Leukemia 2022; 36:1596-1608. [PMID: 35383271 PMCID: PMC9162916 DOI: 10.1038/s41375-022-01553-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 12/24/2022]
Abstract
Fadraciclib (CYC065) is a second-generation aminopurine CDK2/9 inhibitor with increased potency and selectivity toward CDK2 and CDK9 compared to seliciclib (R-roscovitine). In chronic lymphocytic leukemia (CLL), a disease that depends on the over-expression of anti-apoptotic proteins for its survival, inhibition of CDK9 by fadraciclib reduced phosphorylation of the C-terminal domain of RNA polymerase II and blocked transcription in vitro; these actions depleted the intrinsically short-lived anti-apoptotic protein Mcl-1 and induced apoptosis. While the simulated bone marrow and lymph node microenvironments induced Mcl-1 expression and protected CLL cells from apoptosis, these conditions did not prolong the turnover rate of Mcl-1, and fadraciclib efficiently abrogated the protective effect. Further, fadraciclib was synergistic with the Bcl-2 antagonist venetoclax, inducing more profound CLL cell death, especially in samples with 17p deletion. While fadraciclib, venetoclax, and the combination each had distinct kinetics of cell death induction, their activities were reversible, as no additional cell death was induced upon removal of the drugs. The best combination effects were achieved when both drugs were maintained together. Altogether, this study provides a rationale for the clinical development of fadraciclib in CLL, either alone or in combination with a Bcl-2 antagonist.
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Affiliation(s)
- Rong Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yuling Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Xiong
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Plunkett
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Paramithiotis E, Sugden S, Papp E, Bonhomme M, Chermak T, Crawford SY, Demetriades SZ, Galdos G, Lambert BL, Mattison J, McDade T, Pillet S, Murphy R. Cellular Immunity Is Critical for Assessing COVID-19 Vaccine Effectiveness in Immunocompromised Individuals. Front Immunol 2022; 13:880784. [PMID: 35693815 PMCID: PMC9179228 DOI: 10.3389/fimmu.2022.880784] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/12/2022] [Indexed: 12/28/2022] Open
Abstract
COVID-19 vaccine clinical development was conducted with unprecedented speed. Immunity measurements were concentrated on the antibody response which left significant gaps in our understanding how robust and long-lasting immune protection develops. Better understanding the cellular immune response will fill those gaps, especially in the elderly and immunocompromised populations which not only have the highest risk for severe infection, but also frequently have inadequate antibody responses. Although cellular immunity measurements are more logistically complex to conduct for clinical trials compared to antibody measurements, the feasibility and benefit of doing them in clinical trials has been demonstrated and so should be more widely adopted. Adding significant cellular response metrics will provide a deeper understanding of the overall immune response to COVID-19 vaccination, which will significantly inform vaccination strategies for the most vulnerable populations. Better monitoring of overall immunity will also substantially benefit other vaccine development efforts, and indeed any therapies that involve the immune system as part of the therapeutic strategy.
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Affiliation(s)
| | - Scott Sugden
- Scientific Team, CellCarta, Montreal, QC, Canada
| | - Eszter Papp
- Global Research and Development, CellCarta, Montreal, QC, Canada
| | - Marie Bonhomme
- Vaccine Sciences Division, Pharmaceutical Product Development (PPD) Inc., Wilmington, NC, United States
| | - Todd Chermak
- Regulatory and Government Affairs, CellCarta, Montreal, QC, Canada
| | - Stephanie Y. Crawford
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois Chicago, Chicago, IL, United States
| | | | - Gerson Galdos
- Robert J. Havey, MD Institute for Global Health, Northwestern University, Chicago, IL, United States
| | - Bruce L. Lambert
- Center for Communication and Health, Northwestern University, Evanston, IL, United States
| | - John Mattison
- Health Information, Kaiser Permanente, Pasadena, CA, United States
- Health Technology Advisory Board, Arsenal Capital, New York, NY, United States
| | - Thomas McDade
- Department of Anthropology, Northwestern University, Evanston, IL, United States
| | | | - Robert Murphy
- Robert J. Havey, MD Institute for Global Health, Northwestern University, Chicago, IL, United States
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Cherng HJ, Khwaja R, Kanagal‐Shamanna R, Tang G, Burger J, Thompson P, Ferrajoli A, Estrov Z, Sasaki K, Sampath D, Wang X, Kantarjian H, Keating M, Wierda WG, Jain N. TP53-altered chronic lymphocytic leukemia treated with firstline Bruton's tyrosine kinase inhibitor-based therapy: A retrospective analysis. Am J Hematol 2022; 97:1005-1012. [PMID: 35567779 PMCID: PMC9354943 DOI: 10.1002/ajh.26595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/10/2022]
Abstract
Long-term follow up of prospective studies has shown that continuous Bruton's tyrosine kinase inhibitor (BTKi) therapy leads to durable remissions in previously untreated patients with TP53-altered chronic lymphocytic leukemia (CLL); however, it is unknown how variant allele frequency (VAF) of TP53 mutation (TP53-m) or percentage of cells with deletion of chromosome 17p [del(17p)] influences efficacy of firstline BTKi. We performed a retrospective analysis of 130 patients with CLL with baseline del(17p) and/or TP53-m treated with BTKi with or without the BCL2 inhibitor venetoclax (VEN) and with or without CD20 antibody in the firstline setting. A total of 104/130 (80%) patients had del(17p). TP53-m was noted in 89/110 (81%) patients tested; there were 101 unique TP53-m with an available VAF. The 4-year progression-free survival (PFS) and overall survival (OS) rates were 72.9% and 83.6%. No baseline characteristics including IGHV mutation status and number of TP53 alterations were associated with significant differences in PFS or OS, though a trend toward shorter PFS with increasing karyotypic complexity (hazard ratio 1.08, p = .066) was observed. Del(17p) was identified in <25% of cells in 26/104 (25%) of patients, and 28/101 (28%) of TP53-m were low-burden with a VAF of <10%; outcomes of these patients were similar to those with high-burden lesions. This study suggests that low-burden TP53 alterations should not be ignored when assessing genomic risk in CLL in the era of targeted therapy.
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Affiliation(s)
- Hua‐Jay J. Cherng
- Division of Cancer Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Raamis Khwaja
- Department of Internal Medicine The University of Texas Health Science Center at Houston Houston Texas USA
| | - Rashmi Kanagal‐Shamanna
- Department of Hematopathology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Guilin Tang
- Department of Hematopathology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Jan Burger
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Philip Thompson
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Alessandra Ferrajoli
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Zeev Estrov
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Koji Sasaki
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Deepa Sampath
- Department of Hematopoietic Biology and Malignancy The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Xuemei Wang
- Department of Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Hagop Kantarjian
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Michael Keating
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - William G. Wierda
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Nitin Jain
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
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Duarte D, Vale N. Evaluation of synergism in drug combinations and reference models for future orientations in oncology. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100110. [PMID: 35620200 PMCID: PMC9127325 DOI: 10.1016/j.crphar.2022.100110] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/22/2022] [Accepted: 05/07/2022] [Indexed: 12/13/2022] Open
Affiliation(s)
- Diana Duarte
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal
- Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313, Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200, 319, Porto, Portugal
- Corresponding author. OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Dr. Plácido da Costa, 4200-450, Porto, Portugal.
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40
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Zhang J, Lu X, Li J, Miao Y. Combining BTK inhibitors with BCL2 inhibitors for treating chronic lymphocytic leukemia and mantle cell lymphoma. Biomark Res 2022; 10:17. [PMID: 35379357 PMCID: PMC8981798 DOI: 10.1186/s40364-022-00357-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/21/2022] [Indexed: 12/13/2022] Open
Abstract
The advent of BTK inhibitors has changed the treatment of patients with chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL). The first-in-class BTK inhibitor ibrutinib has shown remarkable therapeutic effects and manageable toxicities in multiple clinical trials. The second-generation BTK inhibitors, including acalabrutinib and zanubrutinib, also show remarkable efficacies. However, using BTK inhibitors as monotherapies requires continuous treatment. Resistance to BTK inhibitors and severe side effects unavoidably occur during BTK inhibitor monotherapy, frequently resulting in treatment failure. The addition of the BCL2 inhibitor venetoclax to BTK inhibitor may improve the therapeutic effects and result in deeper responses, providing a potential fixed-duration treatment, especially for patients with CLL. In this review, by focusing on CLL and MCL, we discussed the rationale for the combinational use and summarized the current data on the combinations of BTK inhibitors and venetoclax in patients with CLL and MCL.
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Affiliation(s)
- Jing Zhang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Xueying Lu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China
| | - Jianyong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China. .,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China. .,Pukou CLL Center, Nanjing, China. .,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, China.
| | - Yi Miao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China. .,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, China. .,Pukou CLL Center, Nanjing, China.
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41
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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Yi X, Jain N, Iles LR, Ayres ML, Wierda WG, Gandhi V. Targeting Mcl-1 by AMG-176 During Ibrutinib and Venetoclax Therapy in Chronic Lymphocytic Leukemia. Front Oncol 2022; 12:833714. [PMID: 35273915 PMCID: PMC8901605 DOI: 10.3389/fonc.2022.833714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
B-cell receptor (BCR) signaling pathway and Bcl-2 family prosurvival proteins, specifically Bcl-2 and Mcl-1, are functional in the pathobiology of chronic lymphocytic leukemia (CLL). A pivotal and apical molecule in the BCR pathway is Bruton’s tyrosine kinase (BTK). Together, BTK, Bcl-2, and Mcl-1 participate in the maintenance, migration, proliferation, and survival of CLL cells. Several ongoing and published clinical trials in CLL reported high rates of remission, namely, undetectable measurable residual disease (u-MRD) status with combined BTK inhibitor ibrutinib and Bcl-2 antagonist, venetoclax. While the majority of patients achieve complete remission with undetectable-measurable residual disease, at least one third of patients do not achieve this milestone. We hypothesized that cells persistent during ibrutinib and venetoclax therapy may be sensitive to combined venetoclax and Mcl-1 inhibitor, AMG-176. To test this hypothesis, we took peripheral blood samples at baseline, after Cycle 1 and Cycle 3 of ibrutinib monotherapy, after one week and 1 cycle of ibrutinib plus venetoclax therapy. These serial samples were tested for pharmacodynamic changes and treated in vitro with AMG-176 or in combination with venetoclax. Compared to C1D1 cells, residual cells during ibrutinib and venetoclax treatment were inherently resistant to endogenous cell death. Single agent exposure induced some apoptosis but combination of 100 nM venetoclax and 100 or 300 nM of AMG-176 resulted in 40–100% cell death in baseline samples. Cells obtained after four cycles of ibrutinib and one cycle of venetoclax, when treated with such concentration of venetoclax and AMG-176, showed 10–80% cell death. BCR signaling pathway, measured as autophosphorylation of BTK was inhibited throughout therapy in all post-therapy samples. Among four anti-apoptotic proteins, Mcl-1 and Bfl-1 decreased during therapy in most samples. Proapoptotic proteins decreased during therapy. Collectively, these data provide a rationale to test Mcl-1 antagonists alone or in combination in CLL during treatment with ibrutinib and venetoclax.
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Affiliation(s)
- Xue Yi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - LaKesla R Iles
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mary L Ayres
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Liu L, Cheng X, Yang H, Lian S, Jiang Y, Liang J, Chen X, Mo S, Shi Y, Zhao S, Li J, Jiang R, Yang DH, Wu Y. BCL-2 expression promotes immunosuppression in chronic lymphocytic leukemia by enhancing regulatory T cell differentiation and cytotoxic T cell exhaustion. Mol Cancer 2022; 21:59. [PMID: 35193595 PMCID: PMC8862474 DOI: 10.1186/s12943-022-01516-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/21/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) results in increased susceptibility to infections. T cell dysfunction is not associated with CLL in all patients; therefore, it is important to identify CLL patients with T cell defects. The role of B-cell lymphoma-2 (BCL-2) in CLL has been explored; however, few studies have examined its role in T cells in CLL patients. Herein, we have investigated the regulatory role of BCL-2 in T cells in the CLL tumor microenvironment. METHODS The expression of BCL-2 in T cells was evaluated using flow cytometry. The regulatory roles of BCL-2 were investigated using single-cell RNA sequencing (scRNA-seq) and verified using multi-parameter flow cytometry on CD4 and CD8 T cells. The clinical features of BCL-2 expression in T cells in CLL were also explored. RESULTS We found a significant increase in BCL-2 expression in the T cells of CLL patients (n = 266). Single cell RNA sequencing (scRNA-seq) indicated that BCL-2+CD4+ T cells had the gene signature of increased regulatory T cells (Treg); BCL-2+CD8+ T cells showed the gene signature of exhausted cytotoxic T lymphocytes (CTL); and increased expression of BCL-2 was associated with T cell activation and cellular adhesion. The results from scRNA-seq were verified in peripheral T cells from 70 patients with CLL, wherein BCL-2+CD4+ T cells were enriched with Tregs and had higher expression of interleukin-10 and transforming growth factor-β than BCL-2-CD4+ T cells. BCL-2 expression in CD8+T cells was associated with exhausted cells (PD-1+Tim-3+) and weak expression of granzyme B and perforin. T cell-associated cytokine profiling revealed a negative association between BCL-2+ T cells and T cell activation. Decreased frequencies and recovery functions of BCL-2+T cells were observed in CLL patients in complete remission after treatment with venetoclax. CONCLUSION BCL-2 expression in the T cells of CLL patients is associated with immunosuppression via promotion of Treg abundance and CTL exhaustion.
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Affiliation(s)
- Lu Liu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Xianfeng Cheng
- Department of Clinical laboratory, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, 210042, China
| | - Hui Yang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Senlin Lian
- Jiangsu Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, China.,State Key Laboratory of Pharmaceutical Biotechnology, Medical School, Nanjing University, Nanjing, 210093, China.,Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Yuegen Jiang
- Department of Clinical laboratory, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, 210042, China
| | - Jinhua Liang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Xiao Chen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Suo Mo
- Department of Clinical laboratory, Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, 210042, China
| | - Yu Shi
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Sishu Zhao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Jianyong Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China.,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China
| | - Runqiu Jiang
- Jiangsu Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing, 210093, China. .,State Key Laboratory of Pharmaceutical Biotechnology, Medical School, Nanjing University, Nanjing, 210093, China. .,Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
| | - Dong-Hua Yang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, NY, 11439, USA.
| | - Yujie Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, China. .,Key Laboratory of Hematology of Nanjing Medical University, Nanjing, 210029, China.
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Current Treatment of Chronic Lymphocytic Leukemia: The Diminishing Role of Chemoimmunotherapy. Drugs 2022; 82:133-143. [PMID: 34932207 PMCID: PMC9521791 DOI: 10.1007/s40265-021-01657-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 02/03/2023]
Abstract
In this review, we examine the literature supporting treatment decision making in the front-line and relapsed/refractory settings for patients with chronic lymphocytic leukemia (CLL). In the front-line setting, novel-agent-based approaches, including continuous Bruton tyrosine kinase (BTK) inhibitor-based therapy and time-limited venetoclax with obinutuzumab, have demonstrated survival benefit over chemoimmunotherapy. While novel-agent-based front-line approaches are appropriate for most patients, fludarabine, cyclophosphamide, and rituximab (FCR) remains a consideration for a selected population of young patients with immunoglobulin heavy chain variable region gene (IGHV)-mutated disease because of the possibility of a prolonged remission following FCR. As front-line novel-agent-based approaches have not been compared directly, decision making regarding which novel-agent-based approach to use in the front-line setting is often based on comorbidities and shared decision making. In the relapsed/refractory setting, BTK inhibitors, venetoclax-based therapy, and phosphoinositide 3-kinase (PI3K) inhibitors have demonstrated survival benefit when compared with chemoimmunotherapy regimens. Data to support various treatment sequences are limited, which highlights the need for prospective data to examine the optimal treatment sequence. Finally, we examine therapies with combinations of novel agents, and novel agents in development, including covalent and noncovalent BTK inhibitors, PI3K inhibitors, B-cell lymphoma 2 (BCL2) inhibitors, immunotherapies, and cellular therapies. With effective approved options and new agents in development, the role of chemoimmunotherapy in the management of CLL has diminished.
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Kantarjian HM, Jain N, Garcia-Manero G, Welch MA, Ravandi F, Wierda WG, Jabbour EJ. The cure of leukemia through the optimist's prism. Cancer 2022; 128:240-259. [PMID: 34614211 PMCID: PMC8738114 DOI: 10.1002/cncr.33933] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 01/17/2023]
Abstract
Progress is occurring at a dizzying rate across all leukemias. Since the authors' review of the topic in Cancer in 2018, numerous discoveries have been made that have improved the therapy and outcomes of several leukemia subsets. Hairy cell leukemia is potentially curable with a single course of cladribine followed by rituximab (10-year survival, ≥90%). Acute promyelocytic leukemia is curable at a rate of 80% to 90% with a nonchemotherapy regimen of all-trans retinoic acid and arsenic trioxide. The cure rate for core-binding factor acute myeloid leukemia (AML) is ≥75% with fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin. Survival for patients with chronic myeloid leukemia is close to that for an age-matched normal population with BCR-ABL1 tyrosine kinase inhibitors (TKIs). Chronic lymphocytic leukemia, a previously incurable disease, may now be potentially curable with a finite duration of therapy with Bruton tyrosine kinase inhibitors and venetoclax. The estimated 5-year survival rate for patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL) exceeds 70% with intensive chemotherapy and ponatinib, a third-generation BCR-ABL1 TKI, and more recent nonchemotherapy regimens using dasatinib or ponatinib with blinatumomab are producing outstanding results. Survival in both younger and older patients with ALL has improved with the addition of antibodies targeting CD20, CD19 (blinatumomab), and CD22 (inotuzumab) to chemotherapy. Several recent drug discoveries (venetoclax, FLT3 and IDH inhibitors, and oral hypomethylating agents) are also improving outcomes for younger and older patients with AML and for those with higher risk myelodysplastic syndrome.
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Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Mary Alma Welch
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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High expression level of ROR1 and ROR1-signaling associates with venetoclax resistance in chronic lymphocytic leukemia. Leukemia 2022; 36:1609-1618. [PMID: 35418613 PMCID: PMC9162914 DOI: 10.1038/s41375-022-01543-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/27/2022] [Accepted: 03/09/2022] [Indexed: 12/19/2022]
Abstract
Although the BH3-mimetic venetoclax is highly cytotoxic for chronic lymphocytic leukemia (CLL) cells, some patients with CLL fail to clear minimal residual disease (MRD). We examined the CLL cells of seven such patients (CLL1-7) and found each had high-level expression of ROR1. By examining the CLL cells from such patients prior to therapy at SC1 and then more than 1 year later (Sample Collection 2 (SC2)), when they had progressive increases in MRD despite continued venetoclax therapy, we found the levels of ROR1 expressed on CLL cells at SC2 were significantly higher than that on CLL cells collected at SC1. At SC2, we also observed upregulation of genes induced by Wnt5a-induced ROR1 signaling, including BCL2L1. Transduction of the CLL-cell-line MEC1 to express ROR1 enhanced expression of target genes induced by ROR1-signaling, increased expression of BCL-XL, and enhanced resistance to venetoclax, even in MEC1 made to express mutant forms of BCL2, which are associated with venetoclax resistance. Treatment of primary CLL cells with Wnt5a also increased their resistance to venetoclax, an effect that could be inhibited by the anti-ROR1 mAb (UC-961, zilovertamab). Collectively, these studies indicate that Wnt5a-induced ROR1-signaling can enhance resistance to venetoclax therapy.
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Siddiqui M, Konopleva M. Keeping up with venetoclax for leukemic malignancies: key findings, optimal regimens and clinical considerations. Expert Rev Clin Pharmacol 2021; 14:1497-1512. [PMID: 34791957 DOI: 10.1080/17512433.2021.2008239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Venetoclax has transformed the treatment landscape in hematologic malignancies, especially in elderly population. With high rates of remission, deep and durable responses, and safe toxicity profile, venetoclax in combination therapy has been extremely effective, garnering accelerated approval and becoming standard of care in lymphoid and myeloid malignancies. AREAS COVERED The role of venetoclax in the intrinsic apoptotic pathway is covered. This includes preclinical and clinical experience of venetoclax monotherapy and combination therapy in relapsed/refractory and frontline CLL, AML, ALL and high-risk MDS, with an emphasis on key clinical trials and efficacy of combination regimens in distinct mutational landscapes. Strategies to mitigate myelosuppression, manage dose adjustments and infectious complications are addressed. EXPERT OPINION Targeting BCL-2 offers a safe and highly effective adjunct to available therapies in hematologic malignancies. Despite success and frequent utilization of venetoclax, several resistance mechanisms have been elucidated, prompting development of novel combinatorial strategies. Further, on-target myelosuppression of venetoclax is a key obstacle in clinical practice, requiring diligent monitoring and practice-based knowledge of dose modifications. Despite these limitations, venetoclax has gained tremendous popularity in hematologic-oncology, becoming an integral component of numerous combination regimes, with ongoing plethora of clinical trials encompassing standard chemotherapy, targeted agents and immune-based approaches.
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Affiliation(s)
- Maria Siddiqui
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 428, Houston, TX, 77030, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 428, Houston, TX, 77030, USA
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Woyach JA. Minimal Residual Disease Assessment in CLL/SLL: Is It Ready for Routine Clinical Practice? J Natl Compr Canc Netw 2021. [DOI: 10.6004/jnccn.2021.5107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Minimal residual disease (MRD) in chronic lymphocytic leukemia (CLL) is defined as <1 CLL cell per 10,000 leukocytes (0.01%; <10−4). Flow cytometry and next-generation sequencing have demonstrated high sensitivity in MRD detection. MRD assessment may help to determine prognosis after fixed-duration regimens; this has been established in the contexts of chemoimmunotherapy and venetoclax/antibody combinations. In the short term, MRD status does not seem to inform prognosis in patients treated with a BTK inhibitor plus venetoclax-based regimens; however, long-term data will be needed to determine whether it is beneficial in this population. Numerous trials have demonstrated that MRD may be used to guide therapy. It is unclear whether using an MRD-guided treatment strategy is better than using fixed-duration therapy; ongoing and future studies are warranted.
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49
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Molica S, Seymour JF, Polliack A. A perspective on prognostic models in chronic lymphocytic leukemia in the era of targeted agents. Hematol Oncol 2021; 39:595-604. [PMID: 34596261 DOI: 10.1002/hon.2929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/23/2022]
Abstract
Despite the increase in the number of prognostic models currently available for evaluating patients with chronic lymphocytic leukemia (CLL), their current application and utilization in clinical practice in the era of targeted agents is unclear. A critical reappraisal of recently developed prognostic models is presented in this review. The underlying CLL's genetic instability and changes in the host's health and comorbidities can all contribute to the acquisition of additional risk factors for adverse outcomes during the course of the disease. Therefore, available risk models solely based on pretreatment variables only partially predict patients' clinical outcome. A dynamic prognostic model that takes into account changes in the risk profile over time could indeed be useful in routine clinical practice. The next generation of risk assessment models should incorporate post-treatment and response biomarkers such as minimal residual disease. Finally, recent advances in the field of machine learning present novel opportunities to generate models capable of providing an individualized estimation of clinical outcomes in CLL. However, in the era of improved prognostic models, it is important to remember that these indices should supplement but not replace clinical expertise and medical decision-making.
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Affiliation(s)
- Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - John F Seymour
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Aaron Polliack
- Department of Hematology, Hadassah - Hebrew University Medical Center, Jerusalem, Israel
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Jain N. Evolving Treatment Paradigm in Frontline CLL. JCO Oncol Pract 2021; 18:114-115. [PMID: 34449250 DOI: 10.1200/op.21.00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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