1
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Fisher A, Goradia H, Martinez-Calle N, Patten PEM, Munir T. The evolving use of measurable residual disease in chronic lymphocytic leukemia clinical trials. Front Oncol 2023; 13:1130617. [PMID: 36910619 PMCID: PMC9992794 DOI: 10.3389/fonc.2023.1130617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023] Open
Abstract
Measurable residual disease (MRD) status in chronic lymphocytic leukemia (CLL), assessed on and after treatment, correlates with increased progression-free and overall survival benefit. More recently, MRD assessment has been included in large clinical trials as a primary outcome and is increasingly used in routine practice as a prognostic tool, a therapeutic goal, and potentially a trigger for early intervention. Modern therapy for CLL delivers prolonged remissions, causing readout of traditional trial outcomes such as progression-free and overall survival to be inherently delayed. This represents a barrier for the rapid incorporation of novel drugs to the overall therapeutic armamentarium. MRD offers a dynamic and robust platform for the assessment of treatment efficacy in CLL, complementing traditional outcome measures and accelerating access to novel drugs. Here, we provide a comprehensive review of recent major clinical trials of CLL therapy, focusing on small-molecule inhibitors and monoclonal antibody combinations that have recently emerged as the standard frontline and relapse treatment options. We explore the assessment and reporting of MRD (including novel techniques) and the challenges of standardization and provide a comprehensive review of the relevance and adequacy of MRD as a clinical trial endpoint. We further discuss the impact that MRD data have on clinical decision-making and how it can influence a patient's experience. Finally, we evaluate how upcoming trial design and clinical practice are evolving in the face of MRD-driven outcomes.
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Affiliation(s)
- A. Fisher
- Division of Cancer Studies and Pathology, University of Leeds, Leeds, United Kingdom
- Department of Haematology, Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
| | - H. Goradia
- Department of Haematology, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - N. Martinez-Calle
- Department of Haematology, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - PEM. Patten
- Department of Haematology, Kings College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
- Comprehensive Cancer Centre, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - T. Munir
- Department of Haematology, Leeds Teaching Hospitals National Health Service (NHS) Trust, Leeds, United Kingdom
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2
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Munir T, Emmerson J, Hockaday A, Oughton JB, Howard D, Phillips D, Neilson J, Pemberton N, Paneesha S, Kennedy B, Rawstron A, Hillmen P. Obinutuzumab as consolidation after chemo-immunotherapy: Results of the UK National Cancer Research Institute phase II/III GALACTIC trial. Br J Haematol 2022; 199:707-719. [PMID: 36017875 DOI: 10.1111/bjh.18427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/04/2022] [Accepted: 08/12/2022] [Indexed: 01/07/2023]
Abstract
The GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In chronic lymphocytic leukaemia (CLL) (GALACTIC) was a seamless phase II/III trial designed to test whether consolidation with obinutuzumab is safe and eradicates minimal residual disease (MRD) and, subsequently, whether this leads to prolonged progression-free survival (PFS) in patients with CLL who have recently responded to chemo-immunotherapy. Patients with a response 3-24 months after chemotherapy were assessed for MRD. MRD-positive patients were randomised to receive consolidation therapy with obinutuzumab or no consolidation. The trial closed after the phase II part due to slow recruitment. In all, 48 patients enrolled of whom 19 were MRD negative and were monitored. Of the 29 MRD-positive patients, 14 were randomised to receive consolidation and 15 to no consolidation. At 6 months after randomisation, 10 and 13 consolidated patients achieved MRD negativity by flow cytometry (sensitivity 10-4 ) in bone marrow and peripheral blood respectively. PFS was significantly better in consolidated patients compared to non-consolidated patients (p = 0.001). No difference was observed in PFS, overall survival or duration of MRD negativity when comparing the 10 MRD-negative patients after consolidation with the 19 MRD-negative patients in the monitoring group. Common adverse events in the consolidation arm were thrombocytopenia, infection, and cough. Only 1% of events were infusion-related reactions. This observation provides further evidence that consolidation to achieve MRD negativity improves outcomes in CLL and that obinutuzumab is well tolerated in patients with low levels of disease.
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Affiliation(s)
- Talha Munir
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Jake Emmerson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie B Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Dena Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | | | | | - Andy Rawstron
- Haematological Malignancy Diagnostic Service, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Peter Hillmen
- St James's Institute of Oncology, St James's University Hospital, Leeds, UK
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
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3
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Eyre TA, Hori S, Munir T. Treatment strategies for a rapidly evolving landscape in chronic lymphocytic leukemia management. Hematol Oncol 2021; 40:129-159. [PMID: 34713475 DOI: 10.1002/hon.2943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022]
Abstract
With the advent of targeted therapies for chronic lymphocytic leukemia (CLL), treatment choice has expanded and patients are living longer. Careful consideration is needed regarding treatment duration and sequence, how best to meet patients' needs, balancing toxicities while improving long-term survival and maximizing depth of response. This review addresses these considerations and discusses current targeted treatment dilemmas. Targeted therapies have dramatically transformed the CLL treatment landscape. Two treatment paradigms have emerged using B-cell lymphoma 2 inhibitors (BCL2i) and Bruton's tyrosine kinase (BTK): (i) fixed duration and (ii) continuous treatment. The BCL2i venetoclax can attain deep remissions with a fixed-duration approach, resulting in high rates of undetectable minimal residual disease (uMRD) in treatment-naïve and relapsed/refractory (R/R) patients with CLL. BTKis such as ibrutinib and acalabrutinib achieve high objective response rates and long-term disease control, although they rarely attain complete response or uMRD status as monotherapy. Numerous studies are evaluating the clinical utility of BTKi and BCL2i as combination therapies, where deep remissions have been found to occur. MRD status may also be a useful marker for deciding when to stop continuous therapy, and randomized trials on MRD-guided treatment strategies are currently ongoing. The current treatment choice between continuous or fixed-duration therapy should be based on comorbidities, risks, preferences, and treatment goals, whilst areas of emerging clinical interest include the potential utility of BTKi-BCL2i combination therapies, as well as an MRD-guided treatment strategies in the future.
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Affiliation(s)
- Toby A Eyre
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Talha Munir
- The Leeds Teaching Hospital NHS Trust, St James's University Hospital, Leeds, UK
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4
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Siddiqui R, Sardar M, Shahzad M, Jose J, Selene I, Shah Z, Qureshi A, Shafqat M, Kashif R, Ahmad M, Mejia-Garcia A, Anwer F. Management of Relapsed Hairy Cell Leukemia: A Systematic Review of Novel Agents and Targeted Therapies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:659-666. [PMID: 34275772 DOI: 10.1016/j.clml.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hairy cell leukemia (HCL) responds well to purine analogs with an overall median relapse free survival of 11-16 years. Most patients can be retreated with the same or a different purine analog however a subset of patients will become resistant or develop cumulative toxicities. Novel agents such as Vemurafenib (BRAF kinase inhibitor), Bendamustine/Rituximab (BR), Moxetumomab pasudotox (anti CD-22 recombinant immunotoxin) and Ibrutinib have emerging roles in patients with relapsed HCL. METHODS Five databases (PubMed, Embase, Cochrane Library, Web of Science and ClinicalTrials.gov) were searched using the following search terms: "hairy cell leukemia" or "leukemia, hairy cell" AND "relapse" or "recurrence". We included only prospective clinical trials with outcome data. RESULTS Vemurafenib monotherapy was evaluated in two separate arms of a phase 2 trial. In the US arm (n=24), the ORR was 100% (CR 42%; PR 58%). In the Italian arm (n=26), the ORR was 96% (CR 35%; PR 62%). In a phase 2 study (n=25), the combination of vemurafenib and rituximab showed CR of 100%. The combination of BR achieved an ORR of 100% whereas CR was 50% and 67% at a bendamustine dose of 70mg/m2 (n=6) and 90 mg/m2 (n=6) respectively. In a phase 3 trial, moxetumomab pasudotox (n=80) had an ORR of 75% (CR 41%). Single agent Ibrutinib (n=37) had an ORR of 54%. Therapies were generally well tolerated. CONCLUSION Novel agents have good efficacy in HCL in patients with multiple relapses.
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Affiliation(s)
- Raheel Siddiqui
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City Health and Hospitals/Queens, Jamaica, NY.
| | - Muhammad Sardar
- Department of Hematology and Oncology, Banner University Medical Center, Tucson, AZ
| | - Moazzam Shahzad
- Department of Internal Medicine, St Mary's Medical Center, Huntington, WV
| | - Jemin Jose
- Department of Internal Medicine, Carle Foundation Hospital, Champaign, IL
| | - Insija Selene
- Department of Internal Medicine, Central Michigan University, Saginaw, MI
| | - Zunaira Shah
- Department of Internal Medicine, Louis A Weiss Memorial Hospital, Chicago, IL
| | - Anum Qureshi
- Department of Internal Medicine, Greater Baltimore Medical Center, Towson, MD
| | - Madeeha Shafqat
- Department of Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH
| | - Rimsha Kashif
- Midwestern University College of Osteopathic Medicine, Glendale, AZ
| | - Maheen Ahmad
- Department of Molecular, Cellular and Developmental Biology, University of California, Santa Barbara, CA
| | - Alex Mejia-Garcia
- Department of Hematology-Oncology, Cleveland Clinic- Taussig Cancer Center, Cleveland, OH
| | - Faiz Anwer
- Department of Hematology-Oncology, Cleveland Clinic- Taussig Cancer Center, Cleveland, OH
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5
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Gopalakrishnan S, Wierda W, Chyla B, Menon R, Miles D, Humerickhouse R, Awni W, Salem AH, Mensing S, Freise KJ. Integrated Mechanistic Model of Minimal Residual Disease Kinetics With Venetoclax Therapy in Chronic Lymphocytic Leukemia. Clin Pharmacol Ther 2021; 109:424-432. [PMID: 32749675 DOI: 10.1002/cpt.2005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/26/2020] [Indexed: 12/21/2022]
Abstract
Minimal residual disease (MRD) is an important emerging clinical end point in chronic lymphocytic leukemia (CLL). The objective of this research was to develop an integrated mechanistic model to evaluate the impact of venetoclax-rituximab combination therapy on MRD kinetics. Using data from 435 patients with relapsed or refractory CLL, an integrated model was developed and validated that accounted for venetoclax dosing and pharmacokinetics, rituximab treatment, absolute lymphocyte count, and blood and bone marrow (BM) MRD data. Simulations of venetoclax-rituximab (six cycles) combination predicted the proportion (90% confidence interval) of patients with BM MRD below 10-4 to be 57% (54-61%) and 63% (59-67%) at 12 and 24 months of treatment, respectively. Continued venetoclax treatment to 48 months only increased the predicted rate of negative BM MRD to 66% (63-70%). These results indicate that treatment with venetoclax-rituximab combination for a finite 2-year period would nearly maximize the rate of negative BM MRD (< 10-4 ). Preliminary clinical data agree with these predictions and more long-term follow-up data are awaited to confirm the same.
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Affiliation(s)
- Sathej Gopalakrishnan
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
| | - William Wierda
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brenda Chyla
- Oncology Biomarkers, AbbVie Inc., North Chicago, Illinois, USA
| | - Rajeev Menon
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
| | - Dale Miles
- Genentech Inc., South San Francisco, California, USA
| | | | - Walid Awni
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
| | - Ahmed Hamed Salem
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
- Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Sven Mensing
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
| | - Kevin J Freise
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois, USA
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6
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Abstract
Patients with chronic lymphocytic leukemia can be divided into three categories: those who are minimally affected by the problem, often never requiring therapy; those that initially follow an indolent course but subsequently progress and require therapy; and those that from the point of diagnosis exhibit an aggressive disease necessitating treatment. Likewise, such patients pass through three phases: development of the disease, diagnosis, and need for therapy. Finally, the leukemic clones of all patients appear to require continuous input from the exterior, most often through membrane receptors, to allow them to survive and grow. This review is presented according to the temporal course that the disease follows, focusing on those external influences from the tissue microenvironment (TME) that support the time lines as well as those internal influences that are inherited or develop as genetic and epigenetic changes occurring over the time line. Regarding the former, special emphasis is placed on the input provided via the B-cell receptor for antigen and the C-X-C-motif chemokine receptor-4 and the therapeutic agents that block these inputs. Regarding the latter, prominence is laid upon inherited susceptibility genes and the genetic and epigenetic abnormalities that lead to the developmental and progression of the disease.
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MESH Headings
- Disease Progression
- Humans
- Immunotherapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Mutation
- PAX5 Transcription Factor/metabolism
- Receptors, Antigen, B-Cell
- Signal Transduction
- Tumor Microenvironment
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Affiliation(s)
- Nicholas Chiorazzi
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York 11030, USA
| | - Shih-Shih Chen
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York 11030, USA
| | - Kanti R Rai
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549, USA
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7
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Mora A, Bosch R, Cuellar-García C, Blanco L, Sierra J, Nomdedeu J, Moreno C. Gene expression workflow to analyze residual leukemic cells in Chronic Lymphocytic Leukemia. Int J Lab Hematol 2020; 42:423-430. [PMID: 32333638 DOI: 10.1111/ijlh.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In chronic lymphocytic leukemia, a better understanding of leukemic cell characteristics after treatment would help to design specific therapeutic approaches aimed at preventing clinical relapse. Gene arrays have become a powerful approach to perform gene expression profiling; nevertheless, to work with residual cells entails an intensive labor. The aim of this study was to set forth an effective gene expression approach to analyze residual leukemic cells. METHODS Leukocytes from CLL patient's samples were sorted by flow cytometry using a 6-color panel. The quality and quantity of RNA isolated from different inputs of cells were compared by two silica column protocols: RNeasy Micro and RNeasy Mini. RNA amplifications were carried out according to two manufacturer's protocols: Ovation Pico SL and Ovation Pico WTA. A total of 3.5 μg of cDNA was labeled and hybridized to Human Gene 2.0 ST arrays. RESULTS RNA extracted from low number of input cells by RNeasy Micro showed similar RNA integrity number to that obtained from RNeasy Mini; however, the RNA quantity was higher using the RNeasy Micro Kit. In addition, those RNA samples obtained with RNeasy Micro and amplified with Ovation Pico WTA showed good quality to proceed for a gene array study, independently of the number of input cells (range: 1 × 104 -5 × 105 cells). CONCLUSIONS We observed that this workflow is a feasible approach to obtain genomic material extracted from leukemic cells as little as 1 × 104 cells and it can be useful to carry out gene expression profile experiments to characterize residual leukemic cells in chronic lymphocytic leukemia.
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Affiliation(s)
- Alba Mora
- Laboratory of Oncology/Hematology and Transplantation, Biomedical Research Institute, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Deparment of Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Joseph Carreras Leukemia Research Institute, Barcelona, Spain
| | - Rosa Bosch
- Laboratory of Oncology/Hematology and Transplantation, Biomedical Research Institute, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Carolina Cuellar-García
- Laboratory of Oncology/Hematology and Transplantation, Biomedical Research Institute, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Joseph Carreras Leukemia Research Institute, Barcelona, Spain
| | - Laura Blanco
- Laboratory of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Sierra
- Laboratory of Oncology/Hematology and Transplantation, Biomedical Research Institute, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Deparment of Medicine, Autonomous University of Barcelona, Barcelona, Spain.,Laboratory of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Josep Nomdedeu
- Laboratory of Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Carol Moreno
- Laboratory of Oncology/Hematology and Transplantation, Biomedical Research Institute, IIB Sant Pau, Barcelona, Spain.,Department of Hematology, Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.,Deparment of Medicine, Autonomous University of Barcelona, Barcelona, Spain
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8
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Minimal residual disease analysis in chronic lymphocytic leukemia: a way for achieving more personalized treatments. Leukemia 2018; 32:1307-1316. [DOI: 10.1038/s41375-018-0109-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 11/08/2017] [Accepted: 11/28/2017] [Indexed: 12/28/2022]
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9
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García Vela JA, García Marco JA. Minimal residual disease in chronic lymphocytic leukaemia. Med Clin (Barc) 2018; 150:144-149. [PMID: 28864095 DOI: 10.1016/j.medcli.2017.06.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 11/26/2022]
Abstract
Minimal residual disease (MRD) assessment is an important endpoint in the treatment of chronic lymphocytic leukaemia (CLL). It is highly predictive of prolonged progression-free survival (PFS) and overall survival and could be considered a surrogate for PFS in the context of chemoimmunotherapy based treatment. Evaluation of MRD level by flow cytometry or molecular techniques in the era of the new BCR and Bcl-2 targeted inhibitors could identify the most cost-effective and durable treatment sequencing. A therapeutic approach guided by the level of MRD might also determine which patients would benefit from an early stop or consolidation therapy. In this review, we discuss the different MRD methods of analysis, which source of tumour samples must be analysed, the future role of the detection of circulating tumour DNA, and the potential role of MRD negativity in clinical practice in the modern era of CLL therapy.
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Affiliation(s)
- José Antonio García Vela
- Laboratorio de Citometría de Flujo, Servicio de Hematología y Hemoterapia, Hospital Universitario de Getafe, Getafe, Madrid, España.
| | - José Antonio García Marco
- Laboratorio de Genética Molecular, Servicio de Hematología y Hemoterapia, Hospital Universitario Puerta de Hierro, Madrid, España
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10
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Andresen V, Gjertsen BT. Drug Repurposing for the Treatment of Acute Myeloid Leukemia. Front Med (Lausanne) 2017; 4:211. [PMID: 29238707 PMCID: PMC5712546 DOI: 10.3389/fmed.2017.00211] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/09/2017] [Indexed: 01/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease characterized by the accumulation of immature myeloid progenitor cells in the bone marrow, compromising of normal blood cell production and ultimately resulting in bone marrow failure. With a 20% overall survival rate at 5 years and 50% in the 18- to 65-year-old age group, new medicines are needed. It is proposed that development of repurposed drugs may be a part of the new therapy needed. AML is subdivided into recurrent molecular entities based on molecular genetics increasingly accessible for precision medicine. Novel therapy developments form a basis for novel multimodality therapy and include liposomal daunorubicin/cytarabine, broad or FLT3-specific tyrosine kinase inhibitors, Bcl-2 family inhibitors, selective inhibitors of nuclear export, metabolic inhibitors, and demethylating agents. The use of non-transplant immunotherapy is in early development in AML with the exceptional re-approval of a toxin-conjugated anti-CD33. However, the full potential of small molecule inhibitors and modalities like immunological checkpoint inhibitors, immunostimulatory small molecules, and CAR-T cell therapy is unknown. Some novel therapeutics will certainly benefit AML patient subgroups; however, due to high cost, more affordable alternatives are needed globally. Also the heterogeneity of AML will likely demand a broader repertoire of therapeutic molecules. Drug repurposing or repositioning represent a source for potential therapeutics with well-known toxicity profiles and reasonable prices. This implies that biomarkers of response need to accompany the development of antileukemic therapies for sharply defined patient subgroups. We will illustrate repurposing in AML with selected examples and discuss some experimental and regulatory limitations that may obstruct this development.
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Affiliation(s)
- Vibeke Andresen
- Center for Cancer Biomarkers (CCBIO), Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Bergen, Norway
| | - Bjørn T. Gjertsen
- Center for Cancer Biomarkers (CCBIO), Department of Clinical Science, Precision Oncology Research Group, University of Bergen, Bergen, Norway
- Department of Internal Medicine, Hematology Section, Haukeland University Hospital, Bergen, Norway
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11
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Oughton JB, Collett L, Howard DR, Hockaday A, Munir T, McMahon K, McParland L, Dimbleby C, Phillips D, Rawstron AC, Hillmen P. GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In CLL (GALACTIC) trial: study protocol for a phase II/III randomised controlled trial. Trials 2017; 18:353. [PMID: 28747208 PMCID: PMC5530563 DOI: 10.1186/s13063-017-2107-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common adult leukaemia. Achieving minimal residual disease (MRD) negativity in CLL is an independent predictor of survival even with a variety of different treatment approaches and regardless of the line of therapy. METHODS/DESIGN GA101 (obinutuzumab) monocLonal Antibody as Consolidation Therapy In CLL (GALACTIC) is a seamless phase II/III, multi-centre, randomised, controlled, open, parallel-group trial for patients with CLL who have recently responded to chemotherapy. Participants will be randomised to receive either obinutuzumab (GA-101) consolidation or no treatment (as is standard). The phase II trial will assess safety and short-term efficacy in order to advise on continuation to a phase III trial. The primary objective for phase III is to assess the effect of consolidation therapy on progression-free survival (PFS). One hundred eighty-eight participants are planned to be recruited from forty research centres in the United Kingdom. DISCUSSION There is evidence that achieving MRD eradication with alemtuzumab consolidation is associated with improvements in survival and time to progression. This trial will assess whether obinutuzumab is safe in a consolidation setting and effective at eradicating MRD and improving PFS. TRIAL REGISTRATION ISRCTN, 64035629 . Registered on 12 January 2015. EudraCT, 2014-000880-42 . Registered on 12 November 2014.
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MESH Headings
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Clinical Protocols
- Consolidation Chemotherapy/adverse effects
- Consolidation Chemotherapy/mortality
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Research Design
- Time Factors
- Treatment Outcome
- United Kingdom
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Affiliation(s)
- Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Laura Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Dena R. Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Talha Munir
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Claire Dimbleby
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT UK
| | - Andy C. Rawstron
- Haematological Malignancy Diagnostic Service, St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
| | - Peter Hillmen
- St James’s Institute of Oncology, St James’s University Hospital, Leeds, UK
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12
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Owen C, Christofides A, Johnson N, Lawrence T, MacDonald D, Ward C. Use of minimal residual disease assessment in the treatment of chronic lymphocytic leukemia. Leuk Lymphoma 2017; 58:2777-2785. [DOI: 10.1080/10428194.2017.1318439] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Carolyn Owen
- Division of Hematology and Hematological Malignancies, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - Nathalie Johnson
- Division of Hematology, Jewish General Hospital and Departments of Medicine and Oncology, McGill University, Montreal, Quebec, Canada
| | | | - David MacDonald
- Division of Hematology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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