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Yokus O, Saglam EN, Goze H, Sametoglu F, Serin I. Prognostic Role of Lymphocyte/Monocyte Ratio in Chronic Lymphocytic Leukemia. J Hematol 2020; 9:116-122. [PMID: 33224391 PMCID: PMC7665864 DOI: 10.14740/jh730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 08/18/2020] [Indexed: 11/23/2022] Open
Abstract
Background Chronic lymphocytic leukemia (CLL) is a B-lymphoproliferative disease with varying clinical characteristics, which occurs mostly in older ages. In studies from literature, we see that different parameters are examined to determine the prognosis of CLL. The main purpose of our study is to determine the relationship of lymphocyte/monocyte ratio (LMR) value in CLL, which has been previously shown to be a prognostic factor in various solid organ tumors and some hematological malignancies. Methods A total of 173 patients who were followed up between 2005 and 2019 were retrospectively analyzed. The diagnostic age, gender, laboratory, absolute lymphocyte and monocyte count, LMR and overall survival (OS), treatment and responses, recurrence, cytogenetic subtype and mortality rates were examined. Results The median LMR was 26.7 and it was considered as cut-off value of 26. A positive correlation was found between LMR and Rai Stage. LMR was significantly higher in patients who have an indication for treatment or who died. Conclusions In our study, in CLL, LMR has been shown to be over 26 in advanced stages, in relapse or with indication of a treatment. With the increase of LMR, it was found that survival and disease-free gap decreased.
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Affiliation(s)
- Osman Yokus
- Department of Hematology, University of Health Sciences, Istanbul Training and Research Hospital, Fatih, Istanbul, Turkey
| | - Esma Nur Saglam
- Department of Internal Medicine, University of Health Sciences, Istanbul Training and Research Hospital, Fatih, Istanbul, Turkey
| | - Hasan Goze
- Department of Hematology, University of Health Sciences, Istanbul Training and Research Hospital, Fatih, Istanbul, Turkey
| | - Fettah Sametoglu
- Department of Internal Medicine, University of Health Sciences, Istanbul Training and Research Hospital, Fatih, Istanbul, Turkey
| | - Istemi Serin
- Department of Hematology, University of Health Sciences, Istanbul Training and Research Hospital, Fatih, Istanbul, Turkey
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Scarfò L, Ferreri AJM, Ghia P. Chronic lymphocytic leukaemia. Crit Rev Oncol Hematol 2016; 104:169-82. [PMID: 27370174 DOI: 10.1016/j.critrevonc.2016.06.003] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/01/2016] [Accepted: 06/14/2016] [Indexed: 01/11/2023] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia among the adults in the Western World. CLL (and the corresponding nodal entity small lymphocytic lymphoma, SLL) is classified as a lymphoproliferative disorder characterised by the relentless accumulation of mature B-lymphocytes showing a peculiar immunophenotype in the peripheral blood, bone marrow, lymph nodes and spleen. CLL clinical course is very heterogeneous: the majority of patients follow an indolent clinical course with no or delayed treatment need and with a prolonged survival, while others experience aggressive disease requiring early treatment followed by frequent relapses. In the last decade, the improved understanding of CLL pathogenesis shed light on premalignant conditions (i.e., monoclonal B-cell lymphocytosis, MBL), defined new prognostic and predictive markers, improving patient stratification, but also broadened the therapeutic armamentarium with novel agents, targeting fundamental signaling pathways.
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Affiliation(s)
- Lydia Scarfò
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Andrés J M Ferreri
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Paolo Ghia
- Department of Onco-Haematology, Division of Experimental Oncology, IRCCS San Raffaele Hospital, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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3
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Frustaci AM, Montillo M, Picardi P, Mazzucchelli M, Cairoli R, Tedeschi A. Paving the way for new agents; is standard chemotherapy part of the treatment paradigm for chronic lymphocytic leukemia in the future? Expert Rev Hematol 2016; 9:679-93. [DOI: 10.1080/17474086.2016.1191943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Paola Picardi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Maddalena Mazzucchelli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, Niguarda Hospital, Piazza Ospedale Maggiore 3, Milano, Italy
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Šimkovič M, Motyčková M, Belada D, Vodárek P, Kapoor R, Jaffar H, Vrbacký F, Žák P, Smolej L. Five years of experience with rituximab plus high-dose dexamethasone for relapsed/refractory chronic lymphocytic leukemia. Arch Med Sci 2016; 12:421-7. [PMID: 27186190 PMCID: PMC4848354 DOI: 10.5114/aoms.2016.55425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION High-dose methylprednisolone (HDMP) in combination with rituximab is active in the treatment of relapsed/refractory chronic lymphocytic leukemia (CLL), but serious infections are frequent. Recently published data suggested that high-dose dexamethasone might be equally effective as HDMP despite a lower cumulative dose. MATERIAL AND METHODS We performed retrospective analysis of 60 patients with relapsed/refractory CLL (median age: 66 years; range: 37-86) treated with rituximab plus dexamethasone (R-dex) at a single tertiary center between September 2008 and October 2012. The schedule of R-dex consisted of rituximab 500 mg/m(2) i.v. day 1 (375 mg/m(2) in cycle 1) and dexamethasone 40 mg orally on days 1-4 and 10-13 repeated every 3 weeks for a maximum of 8 cycles. Unfavorable prognostic features were frequent (Rai stages III/IV in 67%, unmutated IgVH 82%, del 11q 43%, TP53 mutation/deletion 23%, bulky lymphadenopathy 58% of patients). RESULTS Overall response (OR)/complete remission (CR) was achieved in 75/3%. At the median follow-up of 21 months, median progression-free survival (PFS) was 8 months, median time to next treatment 12.9 months and median overall survival 25.5 months. Refractoriness to fludarabine (p = 0.04) and age ≥ 65 years (p = 0.03) were significant predictors of shorter PFS. R-dex was successfully used for debulking before allogenic stem cell transplantation in 7 patients (12%). Serious (CTCAE grade III/IV) infections occurred in 27% of patients; 20% of patients developed steroid diabetes requiring temporary short-acting insulin. CONCLUSIONS Our results show that R-dex is an active and well-tolerated regimen for patients with relapsed/refractory CLL; however, major infections remain frequent despite combined antimicrobial prophylaxis.
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Affiliation(s)
- Martin Šimkovič
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Monika Motyčková
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - David Belada
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Pavel Vodárek
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Rahul Kapoor
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Hamna Jaffar
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Filip Vrbacký
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Pavel Žák
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
| | - Lukáš Smolej
- 4 Department of Internal Medicine - Hematology, University Hospital and Charles University in Prague, Faculty of Medicine in Hradec Kralove, Czech Republic
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van Gelder M, van Oers MH, Alemayehu WG, Abrahamse-Testroote MCJ, Cornelissen JJ, Chamuleau ME, Zachée P, Hoogendoorn M, Nijland M, Petersen EJ, Beeker A, Timmers GJ, Verdonck L, Westerman M, de Weerdt O, Kater AP. Efficacy of cisplatin-based immunochemotherapy plus alloSCT in high-risk chronic lymphocytic leukemia: final results of a prospective multicenter phase 2 HOVON study. Bone Marrow Transplant 2016; 51:799-806. [DOI: 10.1038/bmt.2016.9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 12/21/2022]
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6
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Tam CS, Stilgenbauer S. How best to manage patients with chronic lymphocytic leuekmia with 17p deletion and/orTP53mutation? Leuk Lymphoma 2015; 56:587-93. [DOI: 10.3109/10428194.2015.1011641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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7
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Kutsch N, Hallek M, Eichhorst B. Emerging therapies for refractory chronic lymphocytic leukemia. Leuk Lymphoma 2014; 56:285-92. [PMID: 24766469 DOI: 10.3109/10428194.2014.917641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic lymphocytic leukemia (CLL) that becomes refractory to chemotherapy is associated with a poor outcome. For these patients, some of the novel substances that are currently in clinical development for CLL seem to offer new hope. These agents include small molecules, new antibodies, immunomodulators, kinase inhibitors, BCL-2 antagonists and chimeric antigen receptor transduced T-cells (CARTs) and combine high efficacy with a good safety profile. To date, allogeneic stem cell transplant remains the only curative treatment option for patients with relapsed, refractory CLL. However, it is possible that new substances will replace allogeneic stem cell transplant in the near future. This review provides an overview of the currently available data and an outlook on future therapies for chemotherapy refractory CLL.
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Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center of Integrated Oncology (CIO), CECAD (Cluster of Excellence in Cellular Stress Responses in Aging-associated Diseases) and German CLL Study Group (DCLLSG), University of Cologne , Cologne , Germany
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8
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Stankovic T, Skowronska A. The role of ATM mutations and 11q deletions in disease progression in chronic lymphocytic leukemia. Leuk Lymphoma 2013; 55:1227-39. [PMID: 23906020 DOI: 10.3109/10428194.2013.829919] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract ATM gene alteration is a frequent event in pathogenesis of chronic lymphocytic leukemia (CLL) and occurs as monoallelic loss in the form of 11q23 deletion, with and without mutation in the remaining ATM allele. ATM is a principal DNA damage response gene and biallelic ATM alterations lead to ATM functional loss and chemoresistance. The introduction of new therapies, such as intensive chemoimmunotherapy and inhibition of B-cell receptor (BCR) signaling, has changed clinical responses for the majority of CLL tumors including those with 11q deletion, but it remains to be determined whether these strategies can prevent clonal evolution of tumors with biallelic ATM alterations. In this review we discuss ATM function and the consequences of its loss during CLL pathogenesis, differences in clinical behavior of tumors with monoallelic and biallelic ATM alterations, and we outline possible approaches for targeting the ATM null CLL phenotype.
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Affiliation(s)
- Tatjana Stankovic
- School of Cancer Sciences, University of Birmingham , Birmingham , UK
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9
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Cuthill K, Devereux S. How I treat patients with relapsed chronic lymphocytic leukaemia. Br J Haematol 2013; 163:423-35. [DOI: 10.1111/bjh.12549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 07/29/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Kirsty Cuthill
- Department of Haematological Medicine; Kings College; London UK
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10
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Rosenquist R, Cortese D, Bhoi S, Mansouri L, Gunnarsson R. Prognostic markers and their clinical applicability in chronic lymphocytic leukemia: where do we stand? Leuk Lymphoma 2013; 54:2351-64. [PMID: 23480493 DOI: 10.3109/10428194.2013.783913] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is a clinically and biologically heterogeneous disease where the majority of patients have an indolent disease course, while others may experience a far more aggressive disease, treatment failure and poor overall survival. During the last two decades, there has been an intense search to find novel biomarkers that can predict prognosis as well as guide treatment decisions. Two of the most reliable molecular prognostic markers, both of which are offered in routine diagnostics, are the immunoglobulin heavy chain variable (IGHV) gene mutational status and fluorescence in situ hybridization (FISH) detection of prognostically relevant genomic aberrations (e.g. 11q-, 13q-, +12 and 17p-). In addition to these markers, a myriad of additional biomarkers have been postulated as potential prognosticators in CLL, on the protein (e.g. CD38, ZAP70, TCL1), the RNA (e.g. LPL, CLLU1, micro-RNAs) and the genomic (e.g. TP53, NOTCH1, SF3B1 and BIRC3 mutations) level. Efforts are now being made to test these novel markers in larger patient cohorts as well as in prospective trials, with the ultimate goal to combine the "best" markers in a "CLL prognostic index" applicable for the individual patient. Although it is clear that these studies have significantly improved our knowledge regarding both prognostication and the biology of the disease, there is still an immediate need for recognizing biomarkers that can predict therapy response, and efforts should now focus on addressing this pertinent issue. In the present article, we review the extensive literature in the field of prognostic markers in CLL, focus on the most clinically relevant markers and discuss future directions regarding biomarkers in CLL.
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Affiliation(s)
- Richard Rosenquist
- Department of Immunology, Genetics and Pathology, Uppsala University , Uppsala , Sweden
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11
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Warner JL, Arnason JE. Alemtuzumab use in relapsed and refractory chronic lymphocytic leukemia: a history and discussion of future rational use. Ther Adv Hematol 2013; 3:375-89. [PMID: 23606939 DOI: 10.1177/2040620712458949] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
In this review, we outline the clinical experience with single-agent alemtuzumab as a treatment for relapsed and refractory chronic lymphocytic leukemia (CLL) in both prospective and retrospective trials and describe the multiagent use of the drug with the goal of updating clinicians on recent developments and possible future rational combinations. Alemtuzumab, an antibody targeting the lymphocyte-specific surface marker CD52, is an approved agent for the treatment of CLL. Despite its demonstrated efficacy, likely secondary to concerns regarding infectious complications, it is most commonly used in the relapsed and refractory setting. Given alemtuzumab's unique mechanism of action it has been demonstrated to have activity in disease that is refractory to both alkylating agents and purine analogs. Furthermore, it has activity in TP53-mutated disease, which has the worst prognosis of any subset of CLL. Alemtuzumab has greater efficacy on circulating disease relative to nodal disease. Rational combinations are attempting to use these attributes to increase response rates in patients with relapsed and refractory disease.
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Affiliation(s)
- Jeremy L Warner
- Hematologic Malignancy and Bone Marrow Transplantation Program, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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12
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Abstract
BACKGROUND The p53 gene is the most frequently mutated gene in cancer and accordingly has been the subject of intensive investigation for almost 30 years. Loss of p53 function due to mutations has been unequivocally demonstrated to promote cancer in both humans and in model systems. As a consequence, there exists an enormous body of information regarding the function of normal p53 in biology and the pathobiological consequences of p53 mutation. It has long been recognised that analysis of p53 has considerable potential as a tool for use in both diagnostic and, to a greater extent, prognostic settings and some significant progress has been made in both of these arenas. OBJECTIVE To provide an overview of the biology of p53, particularly in the context of uses of p53 as a diagnostic tool. METHODS A literature review focused upon the methods and uses of p53 analysis in the diagnosis of sporadic cancers, rare genetic disorders and in detection of residual disease. CONCLUSION p53 is currently an essential diagnostic for the rare inherited cancer prone syndrome (Li-Fraumeni) and is an important diagnostic in only a limited number of settings in sporadic disease. Research in specific cancers indicates that the uses of increasingly well informed p53 mutational analysis are likely to expand to other cancers.
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Affiliation(s)
- Mark T Boyd
- Reader in Molecular Oncology and Director of Laboratories University of Liverpool, p53/MDM2 Research Team, Division of Surgery and Oncology, School of Cancer Studies, 5th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK +44 151 706 4185 ; +44 151 706 5826 ;
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13
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[Conventional therapeutic strategies for relapsed chronic lymphocytic leukemia]. Bull Cancer 2012; 99:1123-32. [PMID: 23249977 DOI: 10.1684/bdc.2012.1673] [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
The choice of salvage therapy for patients presenting relapsed chronic lymphocytic leukemia (CLL) has to take into account some factors influencing tumor resistance and comorbidities. Since 2010, new drugs targeting the tumor cells' signaling have been proposed for CLL patients. Waiting the results of various clinical trials evaluating these treatments, there is a need to describe the state-of-the-art concerning approved treatments such as chemotherapy and monoclonal antibodies.
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14
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Molica S. The initial approach to patients with chronic lymphocytic leukemia diagnosed in day-to-day practice. Int J Hematol Oncol 2012. [DOI: 10.2217/ijh.12.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY As chronic lymphocytic leukemia (CLL) research increases and new technologies and drugs become available, the landscape of this disease becomes more complex. It is this complexity that suggests the use of practical recommendations in day-to-day practice. The close relationship between early CLL and clinical monoclonal B lymphocytosis regarding clinically relevant parameters does not provide evidence to strictly separate these entities by a distinct threshold of clonal B cells. Prognostic testing and staging procedures based on costs and logistics should be favored at diagnosis, while assessment of more specific markers predicting treatment-related outcome (i.e., 17p del/P53 mutation) should be reserved to patients for whom treatment is required. A diagnosis of CLL, especially in younger patients (<55 years), may cause a number of fears and worries with regard to the course–outcome of the disease. Therefore, communication between the patient and doctor should be informative with respect to the impact of disease on the patient’s affective, social and economic spheres. Finally, current available guidelines should drive the choices of physicians who currently treat CLL patients, with room allowed for consideration of emerging new evidence, physician practice style, patient preference, clinical judgment and patient quality of life. Doctors should also keep in mind that people with CLL want to live their lives as normally as possible; therefore, every effort should be made to ensure the achievement of this goal.
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Affiliation(s)
- Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Viale Pio X, 88100, Catanzaro, Italy
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15
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Baptista MJ, Muntañola A, Calpe E, Abrisqueta P, Salamero O, Fernández E, Codony C, Giné E, Kalko SG, Crespo M, Bosch F. Differential gene expression profile associated to apoptosis induced by dexamethasone in CLL cells according to IGHV/ZAP-70 status. Clin Cancer Res 2012; 18:5924-33. [PMID: 22966019 DOI: 10.1158/1078-0432.ccr-11-2771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Glucocorticoids are part of the therapeutic armamentarium of chronic lymphocytic leukemia (CLL) where it has been suggested that cells with unmutated IGHV genes exhibit higher sensitivity. The mechanisms by which glucocorticoids are active in CLL are not well elucidated. We aimed to ascertain the activity of dexamethasone in CLL cells according to prognosis and to identify the molecular mechanisms that are influencing the response to this drug. EXPERIMENTAL DESIGN Sensitivity to dexamethasone was analyzed ex vivo in 50 CLL and compared according to IGHV mutational status and/or ZAP-70 expression. The response was further compared by gene expression profiling (GEP) of selected cases. Expression of genes of interest was validated by quantitative reverse transcriptase PCR. RESULTS Response to dexamethasone was higher in cases with unmutated IGHV/high ZAP-70 expression, and the levels of induction of the pro-apoptotic Bim protein correlated with the degree of cell death. GEP analysis showed few genes differentially expressed after dexamethasone treatment between mutated and unmutated cases. However, functional annotation analysis showed that unmutated cases had significant enrichment in terms related to apoptosis. Specific analysis of genes of interest conducted in a large series disclosed that in unmutated IGHV cells, FKBP5 expression was higher at baseline and after dexamethasone exposure and that GILZ was more induced by dexamethasone treatment in these cases. CONCLUSIONS Unmutated IGHV/high ZAP-70 CLL cells exhibit better response to dexamethasone treatment, which is accompanied by a differential expression of genes involved in the glucocorticoid receptor pathway and by an increased induction of genes related to apoptosis.
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Affiliation(s)
- Maria Joao Baptista
- Laboratory of Experimental Hematology, Department of Hematology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
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16
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Monitoring chronic lymphocytic leukemia progression by whole genome sequencing reveals heterogeneous clonal evolution patterns. Blood 2012; 120:4191-6. [PMID: 22915640 DOI: 10.1182/blood-2012-05-433540] [Citation(s) in RCA: 262] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic lymphocytic leukemia is characterized by relapse after treatment and chemotherapy resistance. Similarly, in other malignancies leukemia cells accumulate mutations during growth, forming heterogeneous cell populations that are subject to Darwinian selection and may respond differentially to treatment. There is therefore a clinical need to monitor changes in the subclonal composition of cancers during disease progression. Here, we use whole-genome sequencing to track subclonal heterogeneity in 3 chronic lymphocytic leukemia patients subjected to repeated cycles of therapy. We reveal different somatic mutation profiles in each patient and use these to establish probable hierarchical patterns of subclonal evolution, to identify subclones that decline or expand over time, and to detect founder mutations. We show that clonal evolution patterns are heterogeneous in individual patients. We conclude that genome sequencing is a powerful and sensitive approach to monitor disease progression repeatedly at the molecular level. If applied to future clinical trials, this approach might eventually influence treatment strategies as a tool to individualize and direct cancer treatment.
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Rituximab in combination with high-dose dexamethasone for the treatment of relapsed/refractory chronic lymphocytic leukemia. Leuk Res 2012; 36:1278-82. [PMID: 22840362 DOI: 10.1016/j.leukres.2012.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 06/28/2012] [Accepted: 07/02/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND High-dose methylprednisolone is active in treatment of relapsed/refractory chronic lymphocytic leukemia (CLL) but infectious toxicity is serious. The aim of this project was to retrospectively assess efficacy and safety of high-dose dexamethasone combined with rituximab (R-dex) in this setting. PATIENTS AND METHODS We treated 54 patients (pts) with relapsed/refractory CLL using R-dex regimen at two tertiary centers. Two schedules of rituximab were used (not randomized - based on the choice of the center): group 1, rituximab 500 mg/m(2)day 1, 8, 15, 22 (375 mg/m(2) in 1st dose) every 4 weeks (n=29); group 2, 500 mg/m(2)day 1 (375 mg/m(2) in 1st cycle) repeated every 3 weeks (n=25). The target dose of dexamethasone was 40 mg on days 1-4 and 10-13 or 15-18. Rai III/IV stages were present in 82%, unmutated IgVH genes in 82%, del 11q in 38% and del 17p in 19% pts; 46% had bulky lymph nodes; 82% were pretreated with fludarabine and 29% with alemtuzumab. RESULTS Overall response rate/complete remissions were 62/21% (Group 1) and 72/4% (Group 2). In three patients, R-dex was successfully used for debulking before nonmyeloablative allogeneic stem cell transplantation. R-dex was particularly effective in improvement of anemia and thrombocytopenia (p=0.0055 and p=0.0036); B-symptoms resolved after treatment in 11/17 pts. Hematological toxicity was mild. Serious infections occurred in 32% pts. At the median follow-up of 9 and 10 months, median progression-free survival was 6 months in Group 1 and 6.9 months in Group 2 (p=ns); median overall survival was 14.1 months in Group 1 vs. not reached in Group 2 (p=ns). CONCLUSIONS R-dex appears to be an active and feasible treatment for relapsed/refractory CLL. Infectious toxicity remains an important issue. Further investigation of this regimen in larger studies appears fully warranted.
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18
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Veliz M, Pinilla-Ibarz J. Treatment of relapsed or refractory chronic lymphocytic leukemia. Cancer Control 2012; 19:37-53. [PMID: 22143061 DOI: 10.1177/107327481201900105] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent advances in the treatment of chronic lymphocytic leukemia (CLL) have moved beyond the traditional use of alkylating agents and purine analogs into regimens combining these two chemotherapy classes with monoclonal antibodies. METHODS This article reviews treatments options for patients with relapsed or refractory CLL. RESULTS Several studies have investigated novel agents in treating patients with 17p deletion, TP53 mutation, and fludarabine-refractory CLL, as well as patients with suboptimal response to intense treatment. These investigational agents include rituximab, alemtuzumab, ofatumumab, bendamustine, high-dose methylprednisolone, lenalidomide, lumiliximab, cyclin-dependent kinase inhibitors, small modular immunopharmaceuticals, Bcl-2 inhibitors, and histone deacetylase inhibitors. While these newer drugs and combination therapies have shown promise as treatment options for CLL, additional studies are needed to determine the immunosuppression, toxicities, and infections associated with their use. CONCLUSIONS Despite improvement in initial overall response rates, most patients relapse and require further treatment. CLL remains incurable with standard therapies due to development of disease refractoriness. As such, novel approaches such as those noted above warrant continued research to improve outcomes for patients with CLL.
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Affiliation(s)
- Marays Veliz
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL 33612, USA
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Actinomycin D induces p53-independent cell death and prolongs survival in high-risk chronic lymphocytic leukemia. Leukemia 2012; 26:2508-16. [PMID: 22743622 DOI: 10.1038/leu.2012.147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent lymphoid malignancy in the elderly of the Western world. Although treatment options have improved over the past two decades, 10-15% of patients still have a poor prognosis and are often resistant to therapy. Aberrations in the p53 pathway, such as a deleted (del17p13) or mutated p53 gene, are highly enriched in this class of patients. In an extensive screen for p53-independent apoptosis inducers, actinomycin D was identified from 1496 substances and shown to induce apoptosis in primary CLL cells derived from high-risk patients including those with aberrant p53, revealing a novel p53-independent mechanism of action. Both pro-survival genes BCL2 and MCL1 are targeted by actinomycin D, in contrast to fludarabine the backbone of current treatment schedules. In the well-established TCL1 transgenic mouse model for high-risk CLL, actinomycin D treatment was more effective in reducing tumor load than fludarabine, with no evidence of resistance after three treatment cycles and an overall survival increase of over 300%. Tumor load reduction was coupled to BCL2 downregulation. Our results identify the clinically approved compound actinomycin D as a potentially valuable treatment option for CLL high-risk patients.
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Best G, Thompson P, Tam CS. Diagnostic techniques and therapeutic challenges in patients with TP53 dysfunctional chronic lymphocytic leukemia. Leuk Lymphoma 2012; 53:2105-15. [PMID: 22568511 DOI: 10.3109/10428194.2012.692088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Aberrations of the TP53 pathway, whether by deletion or mutation, are increasingly recognized as one of the most important biological risk factors in chronic lymphocytic leukemia. Yet, there is little consensus on how to assess for TP53 defects in the clinic, and very few clinical studies to guide optimal management of such patients. In this review, we discuss the state-of-the-art in the assessment of the TP53 pathway, and review the evidence-base for therapeutic recommendations.
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Affiliation(s)
- Giles Best
- Royal North Shore Hospital, St Leonards, NSW, Australia
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21
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Pettitt AR, Jackson R, Carruthers S, Dodd J, Dodd S, Oates M, Johnson GG, Schuh A, Matutes E, Dearden CE, Catovsky D, Radford JA, Bloor A, Follows GA, Devereux S, Kruger A, Blundell J, Agrawal S, Allsup D, Proctor S, Heartin E, Oscier D, Hamblin TJ, Rawstron A, Hillmen P. Alemtuzumab in Combination With Methylprednisolone Is a Highly Effective Induction Regimen for Patients With Chronic Lymphocytic Leukemia and Deletion of TP53: Final Results of the National Cancer Research Institute CLL206 Trial. J Clin Oncol 2012; 30:1647-55. [DOI: 10.1200/jco.2011.35.9695] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose In chronic lymphocytic leukemia (CLL), TP53 deletion/mutation is strongly associated with an adverse outcome and resistance to chemotherapy-based treatment. In contrast, TP53 defects are not associated with resistance to the anti-CD52 monoclonal antibody alemtuzumab or methylprednisolone. In an attempt to improve the treatment of TP53-defective CLL, a multicenter phase II study was developed to evaluate alemtuzumab and methylprednisolone in combination. Patients and Methods Thirty-nine patients with TP53-deleted CLL (17 untreated and 22 previously treated) received up to 16 weeks of treatment with alemtuzumab 30 mg three times a week and methylprednisolone 1.0 g/m2 for five consecutive days every 4 weeks. Antimicrobial prophylaxis consisted of cotrimoxazole, itraconazole, and aciclovir (or valganciclovir for asymptomatic cytomegalovirus viremia). The primary end point was response as assigned by an end-point review committee. Secondary end points were safety, progression-free survival (PFS) and overall survival (OS). Results The overall response rate, complete response rate (including with incomplete marrow recovery), median PFS, and median OS were 85%, 36%, 11.8 months, and 23.5 months, respectively, in the entire cohort and 88%, 65%, 18.3 months, and 38.9 months, respectively, in previously untreated patients. Grade 3 to 4 hematologic and glucocorticoid-associated toxicity occurred in 67% and 23% of patients, respectively. Grade 3 to 4 infection occurred in 51% of the overall cohort and in 29% of patients less than 60 years of age. Treatment-related mortality was 5%. Conclusion Alemtuzumab plus methypredisolone is the most effective induction regimen hitherto reported in TP53-deleted CLL. The risk of infection is age related and, in younger patients, seems only marginally higher than that associated with rituximab, fludarabine, and cyclophosphamide.
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Affiliation(s)
- Andrew R. Pettitt
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Richard Jackson
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Stacey Carruthers
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - James Dodd
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Susanna Dodd
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Melanie Oates
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Gillian G. Johnson
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Anna Schuh
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Estella Matutes
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Claire E. Dearden
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Daniel Catovsky
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - John A. Radford
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Adrian Bloor
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - George A. Follows
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Stephen Devereux
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Anton Kruger
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Julie Blundell
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Samir Agrawal
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - David Allsup
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Stephen Proctor
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Earnest Heartin
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - David Oscier
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Terry J. Hamblin
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Andrew Rawstron
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
| | - Peter Hillmen
- Andrew R. Pettitt, Richard Jackson, Stacey Carruthers, James Dodd, Susanna Dodd, and Melanie Oates, University of Liverpool; Andrew R. Pettitt and Gillian G Johnson, Royal Liverpool & Broadgreen University Hospitals National Health Service (NHS) Trust, Liverpool; Anna Schuh, Oxford Radcliffe Hospitals NHS Trust, Oxford; Estella Matutes, Claire E. Dearden, and Daniel Catovsky, Institute of Cancer Research and Royal Marsden Hospital NHS Trust, Surrey; John A. Radford and Adrian Bloor, The University of
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Clifford R, Schuh A. State-of-the-Art Management of Patients Suffering from Chronic Lymphocytic Leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:165-78. [PMID: 22474408 PMCID: PMC3315290 DOI: 10.4137/cmo.s6201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of chronic lymphocytic leukemia (CLL) has evolved dramatically in the last decade. For the first time, clinical intervention has been shown to alter the natural history of the disease. Considerable efforts are focussing on better patient selection and response prediction, and it is expected that the publication of the first 200 CLL genomes will spark new insights into risk stratification of CLL patients. Besides, many new agents are being evaluated on their own and in combination therapy in early and late Phase clinical studies. Here, we provide a general clinical introduction into CLL including diagnosis and prognostic markers followed by a summary of the current state-of-the-art treatment. We point to areas of continued clinical research in particular for patients with co-morbidities and highlight the challenges in managing refractory disease.
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Affiliation(s)
- Ruth Clifford
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Churchill Site, Oxford, OX3 7JL, United Kingdom
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Skoetz N, Bauer K, Elter T, Monsef I, Roloff V, Hallek M, Engert A. Alemtuzumab for patients with chronic lymphocytic leukaemia. Cochrane Database Syst Rev 2012; 2012:CD008078. [PMID: 22336834 PMCID: PMC6486055 DOI: 10.1002/14651858.cd008078.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) accounts for 25% of all leukaemias and is the most common lymphoid malignancy in Western countries. Standard treatment includes mono- or poly-chemotherapies. Nowadays, monoclonal antibodies are added, especially alemtuzumab and rituximab. However, the impact of these agents remains unclear, as there are hints of an increased risk of severe infections. OBJECTIVES To assess alemtuzumab compared with no further therapy, or with other anti-leukaemic therapy in patients with CLL. SEARCH METHODS We searched CENTRAL and MEDLINE (from January 1985 to November 2011), and EMBASE (from 1990 to 2009) as well as conference proceedings for randomised controlled trials (RCTs). Two review authors (KB, NS) independently screened search results. SELECTION CRITERIA We included RCTs comparing alemtuzumab with no further therapy or comparing alemtuzumab with anti-leukaemic therapy such as chemotherapy or monoclonal antibodies in patients with histologically-confirmed B-cell CLL. Both pretreated and chemotherapy-naive patients were included. DATA COLLECTION AND ANALYSIS We used hazard ratios (HR) as an effect measure for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) for response rates, treatment-related mortality (TRM) and adverse events. Two review authors independently extracted data and assessed the quality of trials. MAIN RESULTS Our search strategies led to 1542 potentially relevant references. Of these, we included five RCTs involving 845 patients. Overall, we judged the quality of the five trials as moderate. All trials were reported as randomised and open-label studies. However, two trials were published as abstracts only, therefore, we were unable to assess the potential risk of bias for these trials in detail. Because of the small number of studies in each analysis (two), the quantification of heterogeneity was not reliable.Two trials (N = 356) assessed the efficacy of alemtuzumab compared with no further therapy. One trial (N = 335), reported a statistically significant OS advantage for all patients receiving alemtuzumab (HR 0.65 (95% confidence interval (CI) 0.45 to 0.94; P = 0.021). However, no improvement was seen for the subgroup of patients in Rai stage I or II (HR 1.07; 95% CI 0.62 to 1.84; P = 0.82). In both trials, the complete response rate (CRR) (RR 2.61; 95% CI 1.26 to 5.42; P = 0.01) and PFS (HR 0.58; 95% CI 0.44 to 0.76; P < 0.0001) were statistically significantly increased under therapy with alemtuzumab. The potential heterogeneity seen in the forest plot could be due to the different study designs: One trial evaluated alemtuzumab additional to fludarabine as relapse therapy; the other trial examined alemtuzumab compared with no further therapy for consolidation after first remission.There was no statistically significant difference for TRM between both arms (RR 0.57; 95% CI 0.17 to 1.90; P = 0.36). A statistically significant higher rate of CMV reactivation (RR 10.52; 95% CI 1.42 to 77.68; P = 0.02) and infections (RR 1.32; 95% CI 1.01 to 1.74; P = 0.04) occurred in patients receiving alemtuzumab. Seven severe infections (64%) in the alemtuzumab arm in the GCLLSG CLL4B study led to premature closure.Two trials (N = 177), evaluated alemtuzumab versus rituximab. Neither study reported OS or PFS. We could not detect a statistically significant difference for CRR (RR 0.85; 95% CI 0.67 to 1.08; P = 0.18) or TRM (RR 3.20; 95% CI 0.66 to 15.50; P = 0.15) between both arms. However, the CLL2007FMP trial was stopped early due to an increase in mortality in the alemtuzumab arm. More serious adverse events occurred in this arm (43% versus 22% (rituximab), P = 0.006).One trial (N = 297), assessed the efficacy of alemtuzumab compared with chemotherapy (chlorambucil). For this trial, no HR is reported for OS. Median survival has not yet been reached, 84% of patients were alive in each arm at the data cut-off or at the last follow-up date (24.6 months). The TRM between arms shows no statistical significant difference (0.6% versus 2.0%; P = 0.34). Alemtuzumab statistically significantly improves PFS (HR 0.58; 95% CI 0.43 to 0.77; P = 0.0001), time to next treatment (23.3 compared with 14.7 months; P = 0.0001), ORR (83.2% versus 55.4%; P < 0.0001), CRR (24.2% versus 2.0%; P < 0.0001), and minimal residual disease rate (7.4% versus 0%; P = 0.0008) compared with chlorambucil. Statistically, significantly more asymptomatic (51.7% versus 7.4%) and symptomatic cytomegalovirus (CMV) infections (15.4% versus 0%) occurred in the patients treated with alemtuzumab. AUTHORS' CONCLUSIONS In summary, the currently available evidence suggests an OS, CRR and PFS benefit for alemtuzumab compared with no further therapy, but an increased risk for infections in general, CMV infections and CMV reactivations. The role of alemtuzumab versus rituximab still remains unclear, further trials with longer follow-up and overall survival as primary endpoint are needed to evaluate the effects of both agents compared with each other. Alemtuzumab compared with chlorambucil seems to be favourable in terms of PFS, but a longer follow-up period and trials with overall survival as primary endpoint are needed to determine whether this effect will translate into a survival advantage.
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Key Words
- humans
- alemtuzumab
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/therapeutic use
- antibodies, monoclonal, murine‐derived
- antibodies, monoclonal, murine‐derived/therapeutic use
- antineoplastic agents
- antineoplastic agents/therapeutic use
- chlorambucil
- chlorambucil/therapeutic use
- leukemia, lymphocytic, chronic, b‐cell
- leukemia, lymphocytic, chronic, b‐cell/drug therapy
- leukemia, lymphocytic, chronic, b‐cell/mortality
- randomized controlled trials as topic
- rituximab
- vidarabine
- vidarabine/analogs & derivatives
- vidarabine/therapeutic use
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Murine-Derived/therapeutic use
- Antineoplastic Agents/therapeutic use
- Chlorambucil/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Randomized Controlled Trials as Topic
- Rituximab
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
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Affiliation(s)
- Nicole Skoetz
- Cochrane Haematological Malignancies Group, Department I of Internal Medicine, University Hospital of Cologne, Cologne,Germany.
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Cortelezzi A, Gritti G, Laurenti L, Cuneo A, Ciolli S, Di Renzo N, Musto P, Mauro FR, Cascavilla N, Falchi L, Zallio F, Callea V, Maura F, Martinelli S, Piciocchi A, Reda G, Foà R. An Italian retrospective study on the routine clinical use of low-dose alemtuzumab in relapsed/refractory chronic lymphocytic leukaemia patients. Br J Haematol 2011; 156:481-9. [PMID: 22150204 DOI: 10.1111/j.1365-2141.2011.08965.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Low-dose alemtuzumab has shown a favourable toxicity profile coupled with good results in terms of efficacy in relapsed/refractory chronic lymphocytic leukaemia (CLL). We conducted a multicentre retrospective study on the routine clinical use of low-dose alemtuzumab in this patient setting. One hundred and eight relapsed/refractory CLL patients from 11 Italian centres were included in the analysis. All patients had an Eastern Cooperative Oncology Group performance status ≤2 and the majority (84%) had adenopathies <5 cm. Low-dose alemtuzumab was defined as a total weekly dose ≤45 mg and a cumulative dose ≤600 mg given for up to 18 weeks. The overall response rate was 56% (22% complete remissions). After a median follow-up of 42.2 months, the median overall survival and progression-free survival were 39.0 and 19.4 months, respectively. In univariate analysis, response was inversely associated with lymph node (P = 0.01) and spleen (P = 0.02) size, fludarabine-refractoriness (P = 0.01) and del(11q) (P = 0.009). Advanced age and del(17p) were not associated with a worse outcome. Cumulative dose of alemtuzumab was not associated to response. Toxicities were usually mild and manageable; severe infections occurred in seven patients (7%) during therapy. This retrospective analysis confirms that low-dose alemtuzumab is a valid and currently used therapeutic option for the treatment of relapsed/refractory CLL.
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Affiliation(s)
- Agostino Cortelezzi
- Haematology-BMT Unit, IRCCS Ca'Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy.
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Arumainathan A, Kalakonda N, Pettitt AR. Lenalidomide can be highly effective in chronic lymphocytic leukaemia despite T-cell depletion and deletion of chromosome 17p. Eur J Haematol 2011; 87:372-5. [DOI: 10.1111/j.1600-0609.2011.01667.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Zent CS, Kay NE. Management of patients with chronic lymphocytic leukemia with a high risk of adverse outcome: the Mayo Clinic approach. Leuk Lymphoma 2011; 52:1425-34. [PMID: 21649549 PMCID: PMC3448554 DOI: 10.3109/10428194.2011.568654] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) is usually an incidental diagnosis in patients with early-intermediate stage disease. However, most patients with a diagnosis of CLL will subsequently have significant morbidity and die from their disease and its complications. For these patients, CLL is not the 'good leukemia' with a predictably 'benign' outcome. Indeed, we can now identify a cohort of patients with high-risk CLL at diagnosis who will have rapid disease progression, poor response to treatment, and poor survival based on prognostic methods developed from an improved understanding of the biology of CLL. The concomitant development of improved treatments has led to risk-adjusted management approaches that could improve outcomes. We discuss the clinical and laboratory components of comprehensive risk evaluation of patients with CLL and our approach to the management of patients with a high to very high risk of disease progression and poor outcome. In addition, we review the challenges and prospects for improving prognostic precision and the development of new drugs to improve the treatment of patients with CLL with a high risk of adverse outcome.
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Affiliation(s)
- Clive S Zent
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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Abrisqueta P, Crespo M, Bosch F. Personalizing treatment for chronic lymphocytic leukemia. Expert Rev Hematol 2011; 4:27-35. [PMID: 21322776 DOI: 10.1586/ehm.10.84] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the past few years, more effective therapies have emerged in the treatment of chronic lymphocytic leukemia (CLL); these are mainly combinations of immunotherapy with fludarabine-based regimens. Despite the higher response rates obtained with these more intensive treatments, they may not always be applicable. Patients with several comorbidities have an increased toxicity with these newer therapies. Effective tools to distinguish between fit and nonfit patients and new therapeutic approaches suitable for fragile patients with CLL are therefore necessary. Moreover, there is still a subset of patients who are refractory to standard fludarabine-based treatments who continue to have very poor survival. Efforts to understand the mechanisms of resistance to treatment in order to develop new therapeutic agents for those patients are mandatory. Finally, advances in the knowledge of the pathogenesis of CLL are promoting the emergence of drugs directed to new biological targets of this disease. Consequently, trials exploring the toxicity profile and efficacy of these new therapeutic agents, alone or in combination with standard treatments, are warranted.
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Affiliation(s)
- Pau Abrisqueta
- Department of Hematology, University Hospital of Vall d'Hebron 119-129, 08035 Barcelona, Spain
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Tadmor T. Alemtuzumab (Campath-1H) for chronic lymphocytic leukemia: a drug in search of its optimal schedule. Leuk Lymphoma 2011; 52:1831-3. [PMID: 21599582 DOI: 10.3109/10428194.2011.585531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel.
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Zenz T, Fröhling S, Mertens D, Döhner H, Stilgenbauer S. Moving from prognostic to predictive factors in chronic lymphocytic leukaemia (CLL). Best Pract Res Clin Haematol 2011; 23:71-84. [PMID: 20620972 DOI: 10.1016/j.beha.2009.12.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Many prognostic factors have been identified in chronic lymphocytic leukaemia (CLL). Based on the assessment of B cell receptor (BCR) structure and function, a subdivision into subtypes is possible (e.g., immunoglobulin heavy chain variable gene segment (IGHV) unmutated and mutated, V3-21 usage) with distinct biological and clinical characteristics. Recurrent genomic aberrations (i.e., 11q and 17p deletion) and gene mutations (i.e., TP53 and ATM) help to define biological and clinical subgroups. In addition, serum markers (e.g., thymidine kinase (TK) and beta2-microglobulin (beta2-MG)), cellular markers (e.g., CD38 and ZAP70) and clinical staging have an impact on outcome in CLL. The biological characterisation of CLL has not only led to progress in outcome prediction but also has begun to be translated into novel treatment strategies. Nonetheless, most factors associated with prognosis have not been thoroughly interrogated for their predictive value in the light of different therapeutic approaches. With a growing number of agents acting on specific biological targets and being used in different clinical situations, the future is likely to bring the identification of predictive factors in CLL.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Predictive Value of Tests
- Prognosis
- Receptors, Antigen, B-Cell/immunology
- Risk Factors
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Affiliation(s)
- Thorsten Zenz
- Department of Internal Medicine III, University of Ulm, Ulm, Germany
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Hillmen P. Using the biology of chronic lymphocytic leukemia to choose treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:104-109. [PMID: 22160020 DOI: 10.1182/asheducation-2011.1.104] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In recent years, our understanding of the pathophysiology of chronic lymphocytic leukemia (CLL) has advanced significantly. It is now clear that CLL is a relatively proliferative disorder that requires the help of its microenvironment to be maintained and to progress. The stimulation of the CLL cell occurs in most, if not all, patients through antigen stimulation via the BCR. In addition, there is now a clearer appreciation of the role of the p53 pathway leading to chemoresistance. These insights are allowing a more targeted approach with the use of p53-independent drugs such as mAbs and high-dose steroids to overcome genetically poor-risk CLL. The elucidation of the molecular and intracellular signaling mechanisms of disease is just beginning to facilitate the development of several targeted small molecules that promise to revolutionize the treatment of CLL. The measurement of the level of minimal residual disease (MRD) in CLL is becoming more available, facilitating approaches in which the aim of therapy is the eradication of detectable MRD. This also promises to improve personalization of therapy to the individual. Recently, the addition of rituximab to fludarabine plus cyclophosphamide (FCR) has improved overall survival in CLL for the first time, and it appears that this will only be the first small step on the path to much more effective therapies and, hopefully, less toxic targeted therapies.
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Affiliation(s)
- Peter Hillmen
- Institute of Oncology, St James's University Hospital, Leeds, United Kingdom.
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Brown JR. The treatment of relapsed refractory chronic lymphocytic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:110-118. [PMID: 22160021 DOI: 10.1182/asheducation-2011.1.110] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Despite the widespread use of highly effective chemoimmunotherapy (CIT), fludarabine-refractory chronic lymphocytic leukemia (CLL) remains a challenging clinical problem associated with poor overall survival (OS). The traditional definition, which includes those patients with no response or relapse within 6 months of fludarabine, is evolving with the recognition that even patients with longer remissions of up to several years after CIT have poor subsequent treatment response and survival. Approved therapeutic options for these patients remain limited, and the goal of therapy for physically fit patients is often to achieve adequate cytoreduction to proceed to allogeneic stem cell transplantation (alloSCT). Fortunately, several novel targeted therapeutics in clinical trials hold promise of significant benefit for this patient population. This review discusses the activity of available and novel therapeutics in fludarabine-refractory or fludarabine-resistant CLL as well as recently updated data on alloSCT in CLL.
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Affiliation(s)
- Jennifer R Brown
- Harvard Medical School and CLL Center, Dana-Farber Cancer Institute, Boston, MA, USA.
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Fiegl M, Erdel M, Tinhofer I, Brychtova Y, Panovska A, Doubek M, Eigenberger K, Fonatsch C, Hopfinger G, Mühlberger H, Zabernigg A, Falkner F, Gastl G, Mayer J, Greil R. Clinical outcome of pretreated B-cell chronic lymphocytic leukemia following alemtuzumab therapy: a retrospective study on various cytogenetic risk categories. Ann Oncol 2010; 21:2410-2419. [DOI: 10.1093/annonc/mdq236] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Zenz T, Eichhorst B, Busch R, Denzel T, Häbe S, Winkler D, Bühler A, Edelmann J, Bergmann M, Hopfinger G, Hensel M, Hallek M, Döhner H, Stilgenbauer S. TP53 Mutation and Survival in Chronic Lymphocytic Leukemia. J Clin Oncol 2010; 28:4473-9. [DOI: 10.1200/jco.2009.27.8762] [Citation(s) in RCA: 441] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The precise prognostic impact of TP53 mutation and its incorporation into treatment algorithms in chronic lymphocytic leukemia (CLL) is unclear. We set out to define the impact of TP53 mutations in CLL. Patients and Methods We assessed TP53 mutations by denaturing high-performance liquid chromatography (exons 2 to 11) in a randomized prospective trial (n = 375) with a follow-up of 52.8 months (German CLL Study Group CLL4 trial; fludarabine [F] v F + cyclophosphamide [FC]). Results We found TP53 mutations in 8.5% of patients (28 of 328 patients). None of the patients with TP53 mutation showed a complete response. In patients with TP53 mutation, compared with patients without TP53 mutation, median progression-free survival (PFS; 23.3 v 62.2 months, respectively) and overall survival (OS; 29.2 v 84.6 months, respectively) were significantly decreased (both P < .001). TP53 mutations in the absence of 17p deletions were found in 4.5% of patients. PFS and OS for patients with 17p deletion and patients with TP53 mutation in the absence of 17p deletion were similar. Multivariate analysis identified TP53 mutation as the strongest prognostic marker regarding PFS (hazard ratio [HR] = 3.8; P < .001) and OS (HR = 7.2; P < .001). Other independent predictors of OS were IGHV mutation status (HR = 1.9), 11q deletion (HR = 1.9), 17p deletion (HR = 2.3), and FC treatment arm (HR = 0.6). Conclusion CLL with TP53 mutation carries a poor prognosis regardless of the presence of 17p deletion when treated with F-based chemotherapy. Thus, TP53 mutation analysis should be incorporated into the evaluation of patients with CLL before treatment initiation. Patients with TP53 mutation should be considered for alternative treatment approaches.
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Affiliation(s)
- Thorsten Zenz
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Barbara Eichhorst
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Raymonde Busch
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Tina Denzel
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Sonja Häbe
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Dirk Winkler
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Andreas Bühler
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Jennifer Edelmann
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Manuela Bergmann
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Georg Hopfinger
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Manfred Hensel
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Michael Hallek
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Hartmut Döhner
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
| | - Stephan Stilgenbauer
- From the University of Ulm, Ulm; University of Cologne, Cologne; Technical University of Munich; Ludwig-Maximilians-University, Munich; University of Heidelberg, Heidelberg, Germany; and Hanusch Hospital, Vienna, Austria
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MESH Headings
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Chromosome Deletion
- Chromosomes, Human, Pair 11
- Chromosomes, Human, Pair 13
- Chromosomes, Human, Pair 17
- Clinical Trials, Phase III as Topic
- Cyclophosphamide/administration & dosage
- Disease Progression
- Disease-Free Survival
- Drug Administration Schedule
- Humans
- Immunologic Factors/administration & dosage
- In Situ Hybridization, Fluorescence
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Prognosis
- Randomized Controlled Trials as Topic
- Remission Induction
- Rituximab
- Time Factors
- Treatment Outcome
- Vidarabine/administration & dosage
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Peter Hillmen
- Leeds Teaching Hospitals NHS Trust, St James's University Hospital, Leeds LS9 7TF, UK.
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How to improve the treatment outcome in chronic lymphocytic leukemia? Leuk Res 2010; 34:272-5. [DOI: 10.1016/j.leukres.2009.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 07/20/2009] [Accepted: 07/22/2009] [Indexed: 12/18/2022]
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Abstract
There has been considerable progress in the treatment of chronic lymphocytic leukemia (CLL) during last 10 years. Purine analogs and monoclonal antibodies have enabled the shift from purely palliative treatment to intensive regimens aiming at complete remissions and possible prolongation of survival. Many patients have now been shown to achieve molecular responses in addition to their hematological remission. Despite this success, virtually all patients with CLL will eventually relapse and will become refractory to treatment. Allogeneic stem cell transplantation offers a chance of definite cure but is feasible in a minority of patients only. Therefore, considerable effort has been devoted to the further development of more conventional CLL management that is applicable to patient population generally affected by the disease. Emerging treatment concepts include novel combination of well-know agents such as rituximab and chlorambucil, fludarabine, cyclophosphamide and alemtuzumab, FCR with mitoxantrone amongst many. Consolidation regimens using mainly alemtuzumab are also increasingly used but are associated with a major increase in severe infections. High-dose steroids in combination with rituximab or alemtuzumab represent a promising option for refractory patients. Modern chemoimmunotherapy with the FCR regimen has also been tested in early stage patients with unfavourable prognostic factors. Finally, a there are a wide variety of novel drugs including bendamustine, a unique cytostatic with combined properties of an alkylating agent and purine analog, the monoclonal antibodies anti-CD20 ofatumumab and the anti-CD23 lumiliximab, thalidomide and its analog lenalidomide, the semi-synthetic flavonoid flavopiridol and other agents which are currently undergoing clinical trials with promising results. This article reviews the recent advances and future possibilities in the treatment of CLL.
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Affiliation(s)
- Lukas Smolej
- Second Department of Internal Medicine, Department of Clinical Hematology, University Hospital and Medical School, Hradec Kralove, Czech Republic.
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Stilgenbauer S, Zenz T. Understanding and managing ultra high-risk chronic lymphocytic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2010; 2010:481-488. [PMID: 21239840 DOI: 10.1182/asheducation-2010.1.481] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Modern treatment approaches such as chemoimmunotherapy (e.g., fludarabine/cyclophosphamide/rituximab or FCR) are highly effective in the majority of chronic lymphocytic leukemia (CLL) patients. However, there remains a small but challenging subgroup of patients who show ultra high-risk genetics (17p deletion, TP53 mutation) and/or poor response to chemoimmunotherapy. The median life expectancy of these patients is below 2 to 3 years with standard regimens. Accordingly, CLL with the 17p deletion (and likely also with sole TP53 mutation) should be treated with alternative strategies. While p53 defects appear to play a central role in our understanding of this ultra high-risk group, at least half of the cases will not be predictable based on existing prognostic models. Current treatment approaches for patients with p53 defects or poor response to chemoimmunotherapy should rely on agents acting independently of p53, such as alemtuzumab, lenalidomide, flavopiridol, and a growing number of novel compounds (or combinations thereof) currently available in clinical trials. Poor survival times of patients with ultra high-risk CLL suggest that eligible patients should be offered consolidation with reduced-intensity allogeneic stem-cell transplantation or experimental approaches in clinical trials.
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de Viron E, Knoops L, Connerotte T, Smal C, Michaux L, Saussoy P, Vannuffel P, Beert E, Vekemans MC, Hermans C, Bontemps F, Van Den Neste E. Impaired up-regulation of polo-like kinase 2 in B-cell chronic lymphocytic leukaemia lymphocytes resistant to fludarabine and 2-chlorodeoxyadenosine: a potential marker of defective damage response. Br J Haematol 2009; 147:641-52. [PMID: 19764992 DOI: 10.1111/j.1365-2141.2009.07900.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The functional evaluation of ataxia telangiectasia mutated (ATM) and p53 was recently developed in B-cell chronic lymphocytic leukaemia (B-CLL), a disease in which the response to DNA damage is frequently altered. We identified a novel biomarker of chemosensitivity based on the induction of DNA damage by the purine nucleoside analogues (PNA) fludarabine and 2-chlorodeoxyadenosine (CdA). Using genome-wide expression profiling, it was observed that, in chemosensitive samples, PNA predominantly increased the expression of p53-dependent genes, among which PLK2 was the most highly activated at early time points. Conversely, in chemoresistant samples, p53-dependent and PLK2 responses were abolished. Using a quantitative real time polymerase chain reaction, we confirmed that PNA dose- and time-dependently increased PLK2 expression in chemosensitive but not chemoresistant B-CLL samples. Analysis of a larger cohort of B-CLL patients showed that cytotoxicity induced by PNA correlated well with PLK2 mRNA induction. Interestingly, we observed that failure to up-regulate PLK2 following PNA and chemoresistance were not strictly correlated with structural alterations in the TP53 gene. In conclusion, we propose that testing PLK2 activation after a 24-h incubation with PNA could be used to investigate the functional integrity of DNA damage-response pathways in B-CLL cells, and predict clinical sensitivity to these drugs.
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Affiliation(s)
- Emeline de Viron
- De Duve Institute, Université catholique de Louvain, Brussels, Belgium
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Österborg A, Foà R, Bezares RF, Dearden C, Dyer MJS, Geisler C, Lin TS, Montillo M, van Oers MHJ, Wendtner CM, Rai KR. Management guidelines for the use of alemtuzumab in chronic lymphocytic leukemia. Leukemia 2009; 23:1980-8. [DOI: 10.1038/leu.2009.146] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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40
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Stilgenbauer S, Zenz T, Winkler D, Bühler A, Schlenk RF, Groner S, Busch R, Hensel M, Dührsen U, Finke J, Dreger P, Jäger U, Lengfelder E, Hohloch K, Söling U, Schlag R, Kneba M, Hallek M, Döhner H. Subcutaneous alemtuzumab in fludarabine-refractory chronic lymphocytic leukemia: clinical results and prognostic marker analyses from the CLL2H study of the German Chronic Lymphocytic Leukemia Study Group. J Clin Oncol 2009; 27:3994-4001. [PMID: 19597025 DOI: 10.1200/jco.2008.21.1128] [Citation(s) in RCA: 203] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The phase II CLL2H trial evaluated safety and efficacy of subcutaneous alemtuzumab in patients with fludarabine-refractory chronic lymphocytic leukemia (CLL). Clinical and biologic markers were evaluated for their impacts on outcome. PATIENTS AND METHODS One hundred nine patients were enrolled, and 103 received at least one dose of alemtuzumab. After dose escalation, alemtuzumab was administered subcutaneously at 30 mg three times weekly for up to 12 weeks. Response was assessed every 4 weeks during treatment and quarterly thereafter. RESULTS The overall response rate was 34% (complete response, 4%; partial response, 30%). The median progression-free survival was 7.7 months, and the median overall survival (OS) was 19.1 months. Grades 3 to 4 neutropenia, thrombocytopenia, and anemia occurred in 56%, 57%, and 49% of patients, respectively. Grades 3 to 4 noncytomegalovirus and cytomegalovirus infections occurred in 29% and 8% of patients, respectively. Injection-site skin reactions were generally mild. Efficacy did not vary significantly in subgroups defined by genetic parameters (in particular, in 17p deletion, 11q deletion, mutated TP53, and unmutated VH), but efficacy was inferior in patients with increased beta2-microglobulin (beta2-MG) and thymidine kinase (TK). In multivariate analysis of clinical and biologic variables, age, performance status, beta2-MG, and TK were independent prognostic factors for OS. CONCLUSION Subcutaneous alemtuzumab appears as effective and safe as intravenous alemtuzumab in fludarabine-refractory CLL. Subcutaneous administration should be the preferred delivery route because of its efficacy, convenience, improved adverse effect profile, and cost savings. In contrast to chemotherapy-based therapy, alemtuzumab treatment overcomes the adverse prognostic impact of VH mutation status, TP53 mutation, and genomic aberrations.
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Elter T, Molnar I, Kuhlmann J, Hallek M, Wendtner C. Pharmacokinetics of alemtuzumab and the relevance in clinical practice. Leuk Lymphoma 2009; 49:2256-62. [DOI: 10.1080/10428190802475303] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Pettitt AR. Glucocorticoid-based combination therapy for chronic lymphotic leukemia: new tricks for an old dog. Leuk Lymphoma 2009; 49:1843-5. [DOI: 10.1080/10428190802455883] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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2-Phenylacetylenesulfonamide (PAS) induces p53-independent apoptotic killing of B-chronic lymphocytic leukemia (CLL) cells. Blood 2009; 114:1217-25. [PMID: 19515722 DOI: 10.1182/blood-2008-11-190587] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We studied the actions of 2-phenylacetylenesulfonamide (PAS) on B-chronic lymphocytic leukemia (CLL) cells. PAS (5-20 microM) initiated apoptosis within 24 hours, with maximal death at 48 hours asassessed by morphology, cleavage of poly(ADP-ribose) polymerase (PARP), caspase 3 activation, and annexin V staining. PAS treatment induced Bax proapoptotic conformational change, Bax movement from the cytosol to the mitochondria, and cytochrome c release, indicating that PAS induced apoptosis via the mitochondrial pathway. PAS induced approximately 3-fold up-regulation of proapoptotic Noxa protein and mRNA levels. In addition, Noxa was found unexpectedly to be bound to Bcl-2 in PAS-treated cells. PAS treatment of CLL cells failed to up-regulate p53, suggesting that PAS induced apoptosis independently of p53. Furthermore, PAS induced apoptosis in CLL isolates with p53 gene deletion in more than 97% of cells. Normal B lymphocytes were as sensitive to PAS-induced Noxa up-regulation and apoptosis as were CLL cells. However, both T lymphocytes and bone marrow hematopoietic progenitor cells were relatively resistant to PAS. Our data suggest that PAS may represent a novel class of drug that induces apoptosis in CLL cells independently of p53 status by a mechanism involving Noxa up-regulation.
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Lindhagen E, Norberg M, Kanduri M, Tobin G, Säisänen L, Aberg M, Gustafsson MG, Sundström C, Rosenquist R, Aleskog A. In vitro activity of 20 agents in different prognostic subgroups of chronic lymphocytic leukemia--rolipram and prednisolone active in cells from patients with poor prognosis. Eur J Haematol 2009; 83:22-34. [PMID: 19245531 DOI: 10.1111/j.1600-0609.2009.01248.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is a need for development of new drugs for treatment of B-cell chronic lymphocytic leukemia (CLL), especially for poor-prognostic subgroups resistant to conventional therapy. OBJECTIVE The in vitro antileukemic activity of 20 different anticancer agents was characterized in tumor cells from CLL, aiming at identifying agents active in poor-prognostic subgroups. DESIGN AND METHODS In tumor cells from 40 CLL patients and in peripheral blood mononuclear cells (PBMC) from three healthy controls, the activity of 20 substances was assessed using a non-clonogenic assay. The CLL samples were characterized regarding genomic aberrations by interphase fluorescence in situ hybridization and immunoglobulin heavy-chain variable (IGHV) gene mutational status. RESULTS In line with clinical experience, cells from patients with unfavourable genomic aberrations [del(11q)/del(17p)] showed lower drug sensitivity to fludarabine and chlorambucil than cells from patients with favourable cytogenetics [del(13q)/no aberration]. Most investigated drugs demonstrated similar activity in CLL cells from patients with unmutated and mutated IGHV genes as well as in CLL cells vs. PBMC. Interestingly, prednisolone and rolipram displayed high CLL specificity, high activity in CLL cells with unmutated IGHV genes and retained the effect in several cases with 11q/17p deletion. Further studies on prednisolone and rolipram revealed a synergy when these agents were combined in CLL cells, and suggested correlation between drug sensitivity and difference in downstream signaling. CONCLUSION Prednisolone and rolipram are interesting for further studies in CLL with inferior prognosis. The study can also be considered a basis for future efforts to find drugs active in subsets of CLL patients that are resistant to conventional therapy.
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Affiliation(s)
- Elin Lindhagen
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Fiegl M, Gastl G, Hopfinger G, Eigenberger K, Zabernigg A, Schenk T, Falkner F, Falkner A, Sodia S, Doubek M, Brychtova Y, Panovska A, Greil R, Mayer J. Alemtuzumab in chronic lymphocytic leukaemia, other lymphoproliferative disease and autoimmune disorders. MEMO-MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2008. [DOI: 10.1007/s12254-008-0064-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Robak T, Blonski JZ, Wawrzyniak E, Gora-Tybor J, Palacz A, Dmoszynska A, Konopka L, Warzocha K, Jamroziak K. Activity of cladribine combined with cyclophosphamide in frontline therapy for chronic lymphocytic leukemia with 17p13.1/TP53 deletion. Cancer 2008; 115:94-100. [DOI: 10.1002/cncr.24003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Faderl S, Ferrajoli A, Frankfurt O, Pettitt A. Treatment of B-cell chronic lymphocytic leukemia with nonchemotherapeutic agents: experience with single-agent and combination therapy. Leukemia 2008; 23:457-66. [PMID: 18987653 DOI: 10.1038/leu.2008.322] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Recent advances in purine analog-based combination chemotherapy and chemoimmunotherapy have significantly improved response rates and progression-free survival in patients with B-cell chronic lymphocytic leukemia (CLL). However, there are clinical scenarios in which purine analog-based treatment may not be appropriate, either because of the risk of toxicity in patients with comorbidity or because purine analog-based therapies are unlikely to achieve satisfactory responses. Novel, nonchemotherapeutic treatment regimens are becoming increasingly important in these patients, as well as in patients in whom combination chemotherapy-based treatment has failed or resulted in relapse. Nonchemotherapeutic agents include monoclonal antibodies, glucocorticoids, immunomodulatory drugs, drugs with specific intracellular molecular targets, vaccines and cellular immunotherapies. These agents use diverse mechanisms of action that may complement each other, therefore providing a scientific rationale to investigate combinations of these agents in the treatment of CLL. In this review, we will discuss current knowledge of available nonchemotherapeutic agents, available clinical experience with their use alone and in combination and how these approaches may affect outcomes in patients with CLL.
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Affiliation(s)
- S Faderl
- Department of Leukemia, M.D. Anderson Cancer Center, The University of Texas, Houston, TX 77030, USA.
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Monoallelic TP53 inactivation is associated with poor prognosis in chronic lymphocytic leukemia: results from a detailed genetic characterization with long-term follow-up. Blood 2008; 112:3322-9. [PMID: 18689542 DOI: 10.1182/blood-2008-04-154070] [Citation(s) in RCA: 299] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractThe exact prognostic role of TP53 mutations (without 17p deletion) and any impact of the deletion without TP53 mutation in CLL are unclear. We studied 126 well-characterized CLL patients by direct sequencing and DHPLC to detect TP53 mutations (exons 2-11). Most patients with 17p deletions also had TP53 mutations (81%). Mutations in the absence of 17p deletions were found in 4.5%. We found a shorter survival for patients with TP53 mutation (n = 18; P = .002), which was more pronounced when analyzed from the time point of mutation detection (6.8 vs 69 months, P < .001). The survival was equally poor for patients with deletion 17p plus TP53 mutation (7.6 months, n = 13), TP53 mutation only (5.5 months, n = 5), and 17p deletion only (5.4 months, n = 3). The prognostic impact of TP53 mutation (HR 3.71) was shown to be independent of stage, VH status, and 11q and 17p deletion in multivariate analysis. Serial samples showed evidence of clonal evolution and increasing clone size during chemotherapy, suggesting that there may be patients where this treatment is potentially harmful. TP53 mutations are associated with poor sur-vival once they occur in CLL. The de-monstration of clonal evolution under selective pressure supports the biologic significance of TP53 mutations in CLL.
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Best OG, Gardiner AC, Davis ZA, Tracy I, Ibbotson RE, Majid A, Dyer MJS, Oscier DG. A subset of Binet stage A CLL patients with TP53 abnormalities and mutated IGHV genes have stable disease. Leukemia 2008; 23:212-4. [DOI: 10.1038/leu.2008.260] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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