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Smirnova SY, Al-Radi LS, Moiseeva TN, Gemdzhian EG, Yakutik IA, Julhakyan HL, Novikov VA, Galstyan GM, Sudarikov AB. Inhibitor of BRAF V600E Mutation as a Treatment Option for Hairy Cell Leukemia With Deep Neutropenia and Infectious Complications. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:427-430. [PMID: 33811006 DOI: 10.1016/j.clml.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/05/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
Standard therapy in hairy cell leukemia (HCL) is often impossible at the time of deep neutropenia/agranulocytosis with or without infectious complications; it is thus a complex therapeutic problem. Vemurafenib has been used to treat resistant HCL since 2012. Because vemurafenib does not have a myelotoxic effect, we thought that it could be used to treat HCL associated with deep neutropenia/agranulocytosis with or without the development of infectious complications as a preliminary stage before treatment with cladribine. We conducted a retrospective analysis of treatment with vemurafenib followed by a standard course of cladribine provided to 22 patients with deep neutropenia/agranulocytosis with or without infectious complications at diagnosis. Vemurafenib was provided to 22 patients with HCL. The response to therapy was evaluated by complete blood cell count (absolute neutrophil count [ANC], hemoglobin concentration, platelet count, absence of hairy cells), spleen size (assessed by ultrasound), and reduce infectious complications. After that, a standard course of cladribine was provided. Among the 22 patients, the male/female sex ratio was 2:1, and median (range) age was 52 (24-78) years. There were 7 patients with severe infectious manifestations admitted to the intensive care unit, including 1 patient during extracorporeal membrane oxygenation. The median (range) ANC at diagnosis was 0.3 (0.04-0.7) × 109/L. Vemurafenib was provided at a dosage of 240 mg 1 or 2 times a day. In 20 patients, vemurafenib was provided for 3 months or more. In 1 case, the effect was not obtained during 1 month of treatment, and the patient died from severe infectious complications during prolonged agranulocytosis. In 21 patients treated with vemurafenib, an increase of ANC was observed and the infectious complications resolved, thus allowing the application of cladribine therapy. After a standard course (0.1 mg/kg per day for 7 days) of cladribine chemotherapy, 18 patients (90%) experienced complete clinical remission and 2 patients (10%) experienced partial remission with residual splenomegaly. In 1 patient, vemurafenib therapy was still ongoing 2 months after initiating therapy. In cases of proven BRAFV600E mutation, vemurafenib can be successfully used as an effective preliminary therapy in patients with deep neutropenia/agranulocytosis with or without infectious complications before standard therapy with purine analogs.
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Moore JE, Delibert K, Baran AM, Evans AG, Liesveld JL, Zent CS. Targeted therapy for treatment of patients with classical hairy cell leukemia. Leuk Res 2021; 102:106522. [PMID: 33582427 DOI: 10.1016/j.leukres.2021.106522] [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: 01/08/2021] [Revised: 01/20/2021] [Accepted: 01/31/2021] [Indexed: 10/22/2022]
Abstract
Most patients with treatment naïve classical hairy cell leukemia (cHCL) have durable responses with purine nucleoside analogues. In contrast, options are limited for cHCL patients with co-morbidities, purine analogue intolerance, or resistant disease. We report the utility of targeted therapy for nine cHCL patients presenting with treatment naïve cHCL and severe neutropenia and infection (n = 3), purine analogue intolerance (n = 2), or purine analogue resistant disease (n = 4). BRAF inhibitor vemurafenib was started at 240-480 mg twice daily (planned 90-day treatment) and combined with rituximab in seven patients. Therapy was tolerable with no severe adverse events. All patients responded with rapid blood count recovery (median time 1.52 months, range 0.43-4.33). Median progression free and overall survival was not reached at a median follow up of 18.1 months (range 3.2-68.9). These data suggest targeted therapy could be an option for patients unable to be treated with purine analogues.
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Affiliation(s)
- Jeremiah E Moore
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, United States; James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Kendra Delibert
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY, United States; James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Andrea M Baran
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, United States
| | - Andrew G Evans
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Jane L Liesveld
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Clive S Zent
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States.
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3
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Troussard X, Grever MR. The revised guidelines for the diagnosis and management of hairy cell leukaemia and the hairy cell leukaemia variant. Br J Haematol 2020; 193:11-14. [PMID: 33368172 DOI: 10.1111/bjh.17201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Xavier Troussard
- Department of Haematology, CHU Caen Normandie, Caen cedex 9, France
| | - Michael R Grever
- Division of Hematology, The Ohio State University, Columbus, Ohio, USA
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Shorten RJ, Norman J, Sweeney LC. An unusual presentation of Legionella pneumonia in a returning traveller. BMJ Case Rep 2019; 12:12/8/e230130. [PMID: 31420430 DOI: 10.1136/bcr-2019-230130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A male patient in his mid-60s presented with a severe pneumonia following return to the UK after travel to Crete. He was diagnosed with Legionnaire's disease (caused by an uncommon serogroup of Legionella pneumophila). He was pancytopenic on admission, and during a long stay on critical care he was diagnosed with a disseminated Aspergillus infection. Bone marrow aspiration revealed an underlying hairy cell leukaemia that undoubtedly contributed to his acute presentation and subsequent invasive fungal infection.
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Affiliation(s)
- Robert John Shorten
- Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.,Centre for Clinical Microbiology, University College London, London, UK
| | - Jane Norman
- Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Louise C Sweeney
- Microbiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Falini B, Tiacci E. New treatment options in hairy cell leukemia with focus on BRAF inhibitors. Hematol Oncol 2019; 37 Suppl 1:30-37. [PMID: 31187521 DOI: 10.1002/hon.2594] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hairy cell leukemia (HCL) responds initially very well to chemotherapy with purine analogues. However, up to 50% of patients relapse, often multiple times, and become progressively less sensitive to these myelotoxic and immune-suppressive drugs. At progression, viable therapeutic strategies include addition of rituximab to purine analogues, and treatment with the anti-CD22 immunotoxin moxetumomab pasudotox, which has been recently approved by the FDA in HCL patients after at least two prior therapies. Identification of the BRAF-V600E kinase mutation as the genetic cause of HCL has opened the way, in the relapsed/refractory experimental setting, to targeted and non-myelotoxic effective strategies that are based on inhibition of BRAF with vemurafenib, co-inhibition of BRAF and its target MEK with dabrafenib and trametinib, and BRAF inhibition with vemurafenib combined with anti-CD20 immunotherapy. In particular, vemurafenib plus rituximab is emerging as a short, safe, chemotherapy-free regimen able to induce deep complete remissions in most HCL patients refractory to, or relapsed multiple times, after chemo(immuno)therapy.
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Affiliation(s)
- Brunangelo Falini
- Institute of Hematology and CREO (Center for Hemato-Oncological Research), Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - Enrico Tiacci
- Institute of Hematology and CREO (Center for Hemato-Oncological Research), Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
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6
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Geyer MB, Abdel-Wahab O, Tallman MS. BRAF in the cross-hairs. Expert Rev Hematol 2019; 12:183-193. [PMID: 30782032 DOI: 10.1080/17474086.2019.1583553] [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: 10/27/2022]
Abstract
INTRODUCTION Hairy cell leukemia (HCL) is a rare, chronic B-cell lymphoproliferative disorder characterized by distinctive morphologic features and an indolent clinical course. The discovery of a recurrent activating mutation in BRAF (BRAF V600E) as a disease-defining genetic event in HCL has substantial diagnostic and therapeutic implications. Areas covered: Herein the authors review the role of BRAF V600E and RAF-MEK-ERK signaling in the pathogenesis of HCL, anecdotal clinical reports of BRAF inhibitor monotherapy in management of relapsed or refractory HCL, larger phase 2 trials investigating efficacy of BRAF inhibitor therapy for HCL, adverse effects commonly associated with BRAF inhibitor therapy, including cutaneous toxicity, and mechanisms of therapeutic resistance. Expert opinion: Ongoing and planned studies will help to optimize the use of BRAF inhibitor therapy for HCL by determining the efficacy of BRAF inhibition in combination with other antigen targeted or molecularly targeted therapies, and more broadly, to determine how hematologists can best utilize and sequence emerging diagnostic and therapeutic modalities in the care of patients with newly diagnosed and relapsed or refractory HCL.
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Affiliation(s)
- Mark B Geyer
- a Leukemia Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA.,b Cellular Therapeutics Center , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Omar Abdel-Wahab
- a Leukemia Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Martin S Tallman
- a Leukemia Service , Memorial Sloan Kettering Cancer Center , New York , NY , USA
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7
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Roider T, Falini B, Dietrich S. Recent advances in understanding and managing hairy cell leukemia. F1000Res 2018; 7:F1000 Faculty Rev-509. [PMID: 29770206 PMCID: PMC5931274 DOI: 10.12688/f1000research.13265.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 01/15/2023] Open
Abstract
Hairy cell leukemia is a rare B-cell malignancy that is characterized by an indolent course. It was initially described as a distinct entity in 1958. Before the establishment of modern treatment, median survival was only 4 years. Since then, major advances in the treatment and understanding of the biology and genomic landscape of hairy cell leukemia have been made. This review summarizes the present understanding of hairy cell leukemia with particular focus on the development of novel and targeted approaches to treatment.
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Affiliation(s)
- Tobias Roider
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Brunangelo Falini
- Institute of Hematology and Center for Hemato-Oncology Research (CREO), University and Hospital of Perugia, Perugia, Italy
| | - Sascha Dietrich
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
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8
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Abstract
Hairy cell leukemia (HCL) is a chronic mature B-cell neoplasm with unique clinicopathologic features and an initial exquisite sensitivity to chemotherapy with purine analogs; however, the disease relapses, often repeatedly. The enigmatic pathogenesis of HCL was recently clarified by the discovery of its underlying genetic cause, the BRAF-V600E kinase-activating mutation, which is somatically and clonally present in almost all patients through the entire disease spectrum and clinical course. By aberrantly activating the RAF-MEK-ERK signaling pathway, BRAF-V600E shapes key biologic features of HCL, including its specific expression signature, hairy morphology, and antiapoptotic behavior. Accompanying mutations of the KLF2 transcription factor or the CDKN1B/p27 cell cycle inhibitor are recurrent in 16% of patients with HCL and likely cooperate with BRAF-V600E in HCL pathogenesis. Conversely, BRAF-V600E is absent in other B-cell neoplasms, including mimickers of HCL that require different treatments (eg, HCL-variant and splenic marginal zone lymphoma). Thus, testing for BRAF-V600E allows for a genetics-based differential diagnosis between HCL and HCL-like tumors, even noninvasively in routine blood samples. BRAF-V600E also represents a new therapeutic target. Patients' leukemic cells exposed ex vivo to BRAF inhibitors are spoiled of their HCL identity and then undergo apoptosis. In clinical trials of patients with HCL who have experienced multiple relapses after purine analogs or who are refractory to purine analogs, a short course of the oral BRAF inhibitor vemurafenib produced an almost 100% response rate, including complete remission rates of 35% to 42%, without myelotoxicity. To further improve on these results, it will be important to clarify the mechanisms of incomplete leukemic cell eradication by vemurafenib and to explore chemotherapy-free combinations of a BRAF inhibitor with other targeted agents (eg, a MEK inhibitor and/or an anti-CD20 monoclonal antibody).
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Affiliation(s)
- Enrico Tiacci
- All authors: Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
| | - Valentina Pettirossi
- All authors: Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
| | - Gianluca Schiavoni
- All authors: Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
| | - Brunangelo Falini
- All authors: Institute of Hematology and Center for Hemato-Oncology Research, University and Hospital of Perugia, Perugia, Italy
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9
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Grever MR, Abdel-Wahab O, Andritsos LA, Banerji V, Barrientos J, Blachly JS, Call TG, Catovsky D, Dearden C, Demeter J, Else M, Forconi F, Gozzetti A, Ho AD, Johnston JB, Jones J, Juliusson G, Kraut E, Kreitman RJ, Larratt L, Lauria F, Lozanski G, Montserrat E, Parikh SA, Park JH, Polliack A, Quest GR, Rai KR, Ravandi F, Robak T, Saven A, Seymour JF, Tadmor T, Tallman MS, Tam C, Tiacci E, Troussard X, Zent CS, Zenz T, Zinzani PL, Falini B. Consensus guidelines for the diagnosis and management of patients with classic hairy cell leukemia. Blood 2017; 129:553-560. [PMID: 27903528 PMCID: PMC5290982 DOI: 10.1182/blood-2016-01-689422] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 11/06/2016] [Indexed: 12/20/2022] Open
Abstract
Hairy cell leukemia is an uncommon hematologic malignancy characterized by pancytopenia and marked susceptibility to infection. Tremendous progress in the management of patients with this disease has resulted in high response rates and improved survival, yet relapse and an appropriate approach to re-treatment present continuing areas for research. The disease and its effective treatment are associated with immunosuppression. Because more patients are being treated with alternative programs, comparison of results will require general agreement on definitions of response, relapse, and methods of determining minimal residual disease. The development of internationally accepted, reproducible criteria is of paramount importance in evaluating and comparing clinical trials to provide optimal care. Despite the success achieved in managing these patients, continued participation in available clinical trials in the first-line and particularly in the relapse setting is highly recommended. The Hairy Cell Leukemia Foundation convened an international conference to provide common definitions and structure to guide current management. There is substantial opportunity for continued research in this disease. In addition to the importance of optimizing the prevention and management of the serious risk of infection, organized evaluations of minimal residual disease and treatment at relapse offer ample opportunities for clinical research. Finally, a scholarly evaluation of quality of life in the increasing number of survivors of this now manageable chronic illness merits further study. The development of consensus guidelines for this disease offers a framework for continued enhancement of the outcome for patients.
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Affiliation(s)
- Michael R Grever
- Division of Hematology, Department of Internal Medicine, The Ohio State University James Cancer Hospital, Columbus, OH
| | - Omar Abdel-Wahab
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leslie A Andritsos
- Division of Hematology, Department of Internal Medicine, The Ohio State University James Cancer Hospital, Columbus, OH
| | - Versha Banerji
- Section of Hematology/Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Jacqueline Barrientos
- Department of Medicine, Hofstra North Shore-Long Island Jewish School of Medicine, Hofstra University, Hempstead, NY
| | - James S Blachly
- Division of Hematology, Department of Internal Medicine, The Ohio State University James Cancer Hospital, Columbus, OH
| | | | - Daniel Catovsky
- Division of Molecular Pathology, The Institute of Cancer Research, London, United Kingdom
| | - Claire Dearden
- Department of Haemato-Oncology, Royal Marsden Biomedical Research Centre, London, United Kingdom
| | - Judit Demeter
- First Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Monica Else
- Division of Molecular Pathology, The Institute of Cancer Research, London, United Kingdom
| | - Francesco Forconi
- Haematology Department, University Hospital Trust and Cancer Sciences Unit, Cancer Research UK and National Institute for Health Research Experimental Cancer Medicine Centres, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Anthony D Ho
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - James B Johnston
- Section of Hematology/Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Jeffrey Jones
- Division of Hematology, Department of Internal Medicine, The Ohio State University James Cancer Hospital, Columbus, OH
| | - Gunnar Juliusson
- Department of Hematology, Skåne University Hospital and Stem Cell Center, Lund University, Lund, Sweden
| | - Eric Kraut
- Division of Hematology, Department of Internal Medicine, The Ohio State University James Cancer Hospital, Columbus, OH
| | - Robert J Kreitman
- Laboratory of Molecular Biology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Loree Larratt
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Francesco Lauria
- Hematology, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Emili Montserrat
- Department of Hematology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Jae H Park
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aaron Polliack
- Department of Hematology, Hadassah University Hospital and Hebrew University Medical School, Jerusalem, Israel
| | - Graeme R Quest
- Department of Laboratory Medicine and Pathology, University Health Network, Toronto, ON, Canada
| | - Kanti R Rai
- Department of Medicine, Hofstra North Shore-Long Island Jewish School of Medicine, Hofstra University, Hempstead, NY
| | - Farhad Ravandi
- Section of Developmental Therapeutics, Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Lodz, Poland
| | - Alan Saven
- Division of Hematology and Oncology, Scripps Clinic, La Jolla, CA
| | - John F Seymour
- Haematology Department, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, and the Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Constantine Tam
- Haematology Department, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, VIC, Australia
| | - Enrico Tiacci
- Institute of Hematology, Department of Medicine, University and Hospital of Perugia, Perugia, Italy
| | - Xavier Troussard
- Department of Hematology, Centre Hospitalier Universitaire Côte de Nacre, Caen, France
| | - Clive S Zent
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Thorsten Zenz
- Department of Molecular Therapy in Hematology and Oncology, National Center for Tumor Diseases and German Cancer Research Center (DKFZ), Heidelberg, Germany; and
| | - Pier Luigi Zinzani
- Institute of Hematology "Seràgnoli," University of Bologna, Bologna, Italy
| | - Brunangelo Falini
- Institute of Hematology, Department of Medicine, University and Hospital of Perugia, Perugia, Italy
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BRAF V600E mutation in hairy cell leukemia: from bench to bedside. Blood 2016; 128:1918-1927. [DOI: 10.1182/blood-2016-07-418434] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/15/2016] [Indexed: 12/13/2022] Open
Abstract
AbstractHairy cell leukemia (HCL) is a distinct clinicopathological entity whose underlying genetic lesion has remained a mystery for over half a century. The BRAF V600E mutation is now recognized as the causal genetic event of HCL because it is somatic, present in the entire tumor clone, detectable in almost all cases at diagnosis (encompassing the whole disease spectrum), and stable at relapse. BRAF V600E leads to the constitutive activation of the RAF-MEK-extracellular signal-regulated kinase (ERK) signaling pathway which represents the key event in the molecular pathogenesis of HCL. KLF2 and CDNK1B (p27) mutations may cooperate with BRAF V600E in promoting leukemic transformation. Sensitive molecular assays for detecting BRAF V600E allow HCL (highly responsive to purine analogs) to be better distinguished from HCL-like disorders, which are treated differently. In vitro preclinical studies on purified HCL cells proved that BRAF and MEK inhibitors can induce marked dephosphorylation of MEK/ERK, silencing of RAF-MEK-ERK pathway transcriptional output, loss of the HCL-specific gene expression profile signature, change of morphology from “hairy” to “smooth,” and eventually apoptosis. The overall response rate of refractory/relapsed HCL patients to the BRAF inhibitor vemurafenib approached 100%, with 35% to 40% complete remissions (CRs). The median relapse free-survival was about 19 months in patients who had achieved CR and 6 months in those who had obtained a partial response. Future therapeutic perspectives include: (1) combining BRAF inhibitors with MEK inhibitors or immunotherapy (anti-CD20 monoclonal antibody) to increase the percentage of CRs and (2) better understanding of the molecular mechanisms underlying resistance of HCL cells to BRAF inhibitors.
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12
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BRAF inhibition in hairy cell leukemia with low-dose vemurafenib. Blood 2016; 127:2847-55. [PMID: 26941398 DOI: 10.1182/blood-2015-11-680074] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 02/13/2016] [Indexed: 11/20/2022] Open
Abstract
The activating mutation of the BRAF serine/threonine protein kinase (BRAF V600E) is the key driver mutation in hairy cell leukemia (HCL), suggesting opportunities for therapeutic targeting. We analyzed the course of 21 HCL patients treated with vemurafenib outside of trials with individual dosing regimens (240-1920 mg/d; median treatment duration, 90 days). Vemurafenib treatment improved blood counts in all patients, with platelets, neutrophils, and hemoglobin recovering within 28, 43, and 55 days (median), respectively. Complete remission was achieved in 40% (6/15 of evaluable patients) and median event-free survival was 17 months. Response rate and kinetics of response were independent of vemurafenib dosing. Retreatment with vemurafenib led to similar response patterns (n = 6). Pharmacodynamic analysis of BRAF V600E downstream targets showed that vemurafenib (480 mg/d) completely abrogated extracellular signal-regulated kinase phosphorylation of hairy cells in vivo. Typical side effects also occurred at low dosing regimens. We observed the development of acute myeloid lymphoma (AML) subtype M6 in 1 patient, and the course suggested disease acceleration triggered by vemurafenib. The phosphatidylinositol 3-kinase hotspot mutation (E545K) was identified in the AML clone, providing a potential novel mechanism for paradoxical BRAF activation. These data provide proof of dependence of HCL on active BRAF signaling. We provide evidence that antitumor and side effects are observed with 480 mg vemurafenib, suggesting that dosing regimens in BRAF-driven cancers could warrant reassessment in trials with implications for cost of cancer care.
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Dietrich S, Zenz T. BRAF inhibitor therapy in HCL. Best Pract Res Clin Haematol 2015; 28:246-52. [PMID: 26614903 DOI: 10.1016/j.beha.2015.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/28/2015] [Accepted: 10/05/2015] [Indexed: 01/06/2023]
Abstract
Targeted treatment approaches are transforming the therapeutic landscape of cancer care. The discovery of the BRAF V600E mutation in most cases of classical hairy cell leukemia opens up unique opportunities for tumor specific treatment of HCL targeting the MEK/ERK signaling pathway. The discovery and biological implications of BRAF V600E in HCL are summarized to form a basis for our current understanding of the potential for clinical exploitation. There is overwhelming clinical evidence for activity of inhibitors of BRAF in the disease. The review will review current trial activity as well as discuss novel trial concepts exploiting targeted treatment focusing on BRAF inhibition in HCL.
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Affiliation(s)
- Sascha Dietrich
- Department of Translational Oncology, National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany; Department of Medicine V, Heidelberg University Medical Center, Heidelberg, Germany; Genome Biology Unit, European Molecular Biology Laboratory, Heidelberg, Germany
| | - Thorsten Zenz
- Department of Translational Oncology, National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany; Department of Medicine V, Heidelberg University Medical Center, Heidelberg, Germany.
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Cornet E, Damaj G, Troussard X. New insights in the management of patients with hairy cell leukemia. Curr Opin Oncol 2015; 27:371-6. [PMID: 26154707 DOI: 10.1097/cco.0000000000000214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Although hairy cell leukemia (HCL) was identified in 1958 by Bouroncle and colleagues, HCL remains in 2015 a mysterious disease. Accurate diagnosis of HCL relies on the recognition of hairy cells by morphology and flow cytometry in blood and/or bone marrow. However, there are cases difficult to diagnose, particularly in variants of HCL. Furthermore, some diseases such as splenic diffuse red pulp small B-cell lymphoma are very close to HCL and may be misdiagnosed. Major advances in the management of patients who have HCL have been made following the use of purine nucleoside analogs. However, new treatment options can be available in relapsed/refractory HCL: monoclonal antibody therapy, BRAF inhibitors, or immunotoxins. RECENT FINDINGS The presence of the BRAFV600E mutation was recently identified in most cases of HCL and its absence in variants of HCL and in other B-cell chronic lymphoproliferative disorders. The precise cellular origin of HCL remains elusive but BRAF mutations were detected in hematopoietic stem cells of patients with HCL. Assessment for minimal residual disease is important in clinical trials. Minimal residual disease detection can clearly predict inferior long-term outcomes or early relapses in patients with HCL. Recent reports have shown that inhibition of BRAF kinase by drugs such as vemurafenib is effective in relapsed/refractory HCL. Immunotoxins offer new opportunities even in patients without BRAF mutations. SUMMARY All these findings have major implications for diagnosis, monitoring, and treatment of HCL and variant forms of HCL.
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Affiliation(s)
- Edouard Cornet
- aLaboratoire Hématologie bService Hématologie Clinique, CHU Côte de Nacre, Caen, France
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15
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Abstract
Hairy cell leukemia was initially described as a distinct entity in 1958. It is rare B-cell malignancy characterized by an indolent course. Advances in the treatment and understanding of the biology of hairy cell leukemia have made the disease exquisitely amenable to treatment. This review summarizes the present understanding of hairy cell leukemia with a particular focus on the development of novel and targeted approaches to treatment.
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Abstract
The majority of patients with hairy cell leukemia (HCL) achieve a response to therapy with cladribine or pentostatin with or without rituximab. However, late relapses can occur. Treatment of relapsed HCL can be difficult due to a poor tolerance to chemotherapy, increased risk of infections and decreased responsiveness to chemotherapy. The identification of BRAFV600E mutations and the role of aberrant MEK kinase and Bruton's tyrosine kinase (BTK) pathways in the pathogenesis of HCL have helped to develop novel targeted therapies for these patients. Currently, the most promising therapeutic strategies for relapsed or refractory HCL include recombinant immunoconjugates targeting CD22 (e.g. moxetumomab pasudotox), BRAF inhibitors such as vemurafenib and B cell receptor signaling kinase inhibitors such as ibrutinib. Furthermore, the VH4-34 molecular variant of classic HCL has been identified to be less responsive to chemotherapy. Herein, we review the results of the ongoing clinical trials and potential future therapies for relapsed/refractory HCL.
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Affiliation(s)
- Preetesh Jain
- a Department of Leukemia , University of Texas M. D. Anderson Cancer Center , Houston , TX , USA
| | - Aaron Polliack
- b Department of Hematology , Hadassah University Hospital, Hebrew University Medical School , Jerusalem , Israel
| | - Farhad Ravandi
- a Department of Leukemia , University of Texas M. D. Anderson Cancer Center , Houston , TX , USA
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17
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Rapid and complete hematological response of refractory hairy cell leukemia to the BRAF inhibitor dabrafenib. Ann Hematol 2014; 93:2087-9. [DOI: 10.1007/s00277-014-2104-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
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18
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Treatment of refractory hairy cell leukemia with a BRAF-inhibitor: lessons to be learnt. Pathol Oncol Res 2014; 20:973-80. [PMID: 24789721 DOI: 10.1007/s12253-014-9783-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/10/2014] [Indexed: 01/23/2023]
Abstract
Hairy cell leukemia is a rare chronic lymphoproliferative disorder with indolent but progressive clinical course. Patients require treatment when they have significant cytopenia or recurrent infections. The gold standard treatment are purine nucleoside analogues (cladribine and pentostatine), with these agents the rate of complete remission can approach even 95 %. The differential diagnosis between classical hairy cell leukemia and other, rare splenic lymphomas that can mimic this disease might be really challenging. Splenic lymphoma with villous lymphocytes and other new, provisional WHO entities share some, but not all immunophenotypical features with hairy cell leukemia. The correct diagnosis is of an extreme importance as these entities require different treatment. Thus further investigation in the pathogenesis of hairy cell leukemia is required in order to solve this challenge. Discovery of the BRAF V600E mutation as a disease-defining genetic event in hairy cell leukemia can be helpful in both differential diagnosis and treatment of this disease. We report the case of three hairy cell leukemia patients, whose diagnosis or treatment was based on this newly discovered somatic mutation, but the treatment results and side effects were individual.
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