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Kittai AS, Allan JN, James D, Bridge H, Miranda M, Yong ASM, Fam F, Roos J, Shetty V, Skarbnik A, Davids MS. An indirect comparison of acalabrutinib with and without obinutuzumab vs zanubrutinib in treatment-naive CLL. Blood Adv 2024; 8:2861-2869. [PMID: 38598745 PMCID: PMC11176945 DOI: 10.1182/bloodadvances.2023012142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024] Open
Abstract
ABSTRACT The efficacy and safety of acalabrutinib plus obinutuzumab and acalabrutinib monotherapy vs zanubrutinib in patients with treatment-naive chronic lymphocytic leukemia/small lymphocytic lymphoma without del(17p) were compared using an unanchored matching-adjusted indirect comparison. Individual patient-level data from ELEVATE-TN (acalabrutinib plus obinutuzumab, n = 162; acalabrutinib monotherapy, n = 163) were weighted to match published aggregate baseline data from SEQUOIA cohort 1, which excluded patients with del(17p) (zanubrutinib, n = 241), using variables that were prognostic/predictive of investigator-assessed progression-free survival (INV-PFS) in an exploratory Cox regression analysis of ELEVATE-TN. After matching, INV-PFS was longer with acalabrutinib plus obinutuzumab (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.23-0.74) and comparable with acalabrutinib monotherapy (HR, 0.91; 95% CI, 0.53-1.56) vs zanubrutinib. Acalabrutinib monotherapy had significantly lower odds of any grade hypertension vs zanubrutinib (odds ratio [OR], 0.44; 95% CI, 0.20-0.99), whereas acalabrutinib plus obinutuzumab had significantly higher odds of neutropenia (OR, 2.19; 95% CI, 1.33-3.60) and arthralgia (OR, 2.33; 95% CI, 1.37-3.96) vs zanubrutinib. No other significant differences in safety were observed. In summary, acalabrutinib plus obinutuzumab had longer INV-PFS with increased odds of neutropenia and arthralgia than zanubrutinib, whereas acalabrutinib monotherapy had similar INV-PFS with lower odds of any grade hypertension. These trials were registered at www.ClinicalTrials.gov as #NCT02475681 and #NCT03336333.
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MESH Headings
- Humans
- Benzamides/therapeutic use
- Benzamides/administration & dosage
- Benzamides/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/administration & dosage
- Pyrazines/administration & dosage
- Pyrazines/therapeutic use
- Pyrazines/adverse effects
- Female
- Male
- Aged
- Pyrimidines/therapeutic use
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrazoles/therapeutic use
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Middle Aged
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Aged, 80 and over
- Treatment Outcome
- Piperidines
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Affiliation(s)
- Adam S. Kittai
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Dan James
- Polaris Biostatistics Ltd, Edinburgh, United Kingdom
| | - Helen Bridge
- AstraZeneca, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Miguel Miranda
- AstraZeneca, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | | | - Fady Fam
- AstraZeneca, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | | | | | - Alan Skarbnik
- Novant Health Cancer Institute, Lymphoma and CLL Program, Charlotte, NC
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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2
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Javidi-Sharifi N, Brown JR. Evaluating zanubrutinib for the treatment of adults with chronic lymphocytic leukemia or small lymphocytic lymphoma. Expert Rev Hematol 2024; 17:201-210. [PMID: 38784995 DOI: 10.1080/17474086.2024.2356257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION This review evaluates zanubrutinib as a treatment option for adults with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Zanubrutinib, a covalent BTK (Bruton's tyrosine kinase) inhibitor, was recently approved by the US FDA based in part on head-to-head data demonstrating improved efficacy and safety compared to ibrutinib. AREAS COVERED The review discusses the efficacy, safety, and comparative advantages of zanubrutinib, highlighting its safety profile compared to other BTK inhibitors. It also addresses the unmet needs of current therapies in CLL/SLL and provides an overview of competitor compounds and ongoing research in BTK inhibition. EXPERT OPINION Zanubrutinib, the first BTK inhibitor to demonstrate superior efficacy and safety compared to another BTK inhibitor in CLL, is likely to be widely adopted due to its high-quality data and ease of use. Looking ahead, pirtobrutinib, a novel non-covalent BTK inhibitor, has shown promise in heavily pretreated CLL patients, including those unresponsive to covalent inhibitors, with ongoing phase 3 trials comparing it against ibrutinib. The field is also exploring time-limited therapies like the combination of ibrutinib and venetoclax, with ongoing trials evaluating different combinations to optimize efficacy and minimize toxicity, indicating a promising future for combination therapies in CLL treatment.
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Affiliation(s)
- Nathalie Javidi-Sharifi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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3
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Samples L, Voutsinas J, Fakhri B, Khajavian S, Spurgeon S, Stephens D, Skarbnik A, Mato A, Broome C, Gopal A, Smith S, Lynch R, Rainey M, Kim MS, Barrett-Campbell O, Hemond E, Tsang M, Ermann D, Malakhov N, Rao D, Shakib-Azar M, Morrigan B, Chauhan A, Plate T, Gooley T, Ryan K, Lansigan F, Hill B, Pongas G, Parikh SA, Roeker L, Allan JN, Cheng R, Ujjani C, Shadman M. Hypertension treatment for patients receiving ibrutinib: a multicenter retrospective study. Blood Adv 2024; 8:2085-2093. [PMID: 38315043 PMCID: PMC11063398 DOI: 10.1182/bloodadvances.2023011569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/30/2023] [Accepted: 11/19/2023] [Indexed: 02/07/2024] Open
Abstract
ABSTRACT Although Bruton tyrosine kinase inhibitors (BTKis) are generally well tolerated and less toxic than chemotherapy alternatives used to treat lymphoid malignancies, BTKis like ibrutinib have the potential to cause new or worsening hypertension (HTN). Little is known about the optimal treatment of BTKi-associated HTN. Randomly selected patients with lymphoid malignancies on a BTKi and antihypertensive drug(s) and with at least 3 months of follow-up data were sorted into 2 groups: those diagnosed with HTN before BTKi initiation (prior-HTN), and those diagnosed with HTN after BTKi initiation (de novo HTN). Generalized estimating equations assessed associations between time varying mean arterial pressures (MAPs) and individual anti-HTN drug categories. Of 196 patients included in the study, 118 had prior-HTN, and 78 developed de novo HTN. Statistically significant mean MAP reductions were observed in patients with prior-HTN who took β blockers (BBs) with hydrochlorothiazide (HCTZ), (-5.05 mmHg; 95% confidence interval [CI], 10.0 to -0.0596; P = .047), and patients diagnosed with de novo HTN who took either an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) with HCTZ (-5.47 mmHg; 95% CI, 10.9 to -0.001; P = .05). These regimens also correlated with the greatest percentages of normotensive MAPs. Treatment of HTN in patients taking a BTKi is challenging and may require multiple antihypertensives. Patients with prior-HTN appear to benefit from combination regimens with BBs and HCTZ, whereas patients with de novo HTN appear to benefit from ACEi/ARBs with HCTZ. These results should be confirmed in prospective studies.
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Affiliation(s)
- Laura Samples
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
| | - Jenna Voutsinas
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Bita Fakhri
- Division of Hematology and Oncology, University of California, San Francisco, CA
| | - Sirin Khajavian
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Stephen Spurgeon
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR
| | - Deborah Stephens
- Division of Hematology and Hematologic Malignancies, The University of Utah, Salt Lake City, UT
| | | | - Anthony Mato
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Catherine Broome
- Division of Hematology and Oncology, Georgetown University, Washington, DC
| | - Ajay Gopal
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
| | - Stephen Smith
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
| | - Ryan Lynch
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
| | - Magdalena Rainey
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Myung Sun Kim
- Division of Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR
| | | | - Emily Hemond
- Hematology/Oncology Section, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Mazie Tsang
- Division of Hematology and Oncology, University of California, San Francisco, CA
| | - Daniel Ermann
- Division of Hematology and Hematologic Malignancies, The University of Utah, Salt Lake City, UT
| | - Nikita Malakhov
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Danielle Rao
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Beth Morrigan
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Ayushi Chauhan
- Division of Hematology and Oncology, Georgia Cancer Center, Augusta University, Augusta, GA
| | - Thomas Plate
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Ted Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Frederick Lansigan
- Hematology/Oncology Section, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Brian Hill
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH
| | - Georgios Pongas
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | | | - Lindsey Roeker
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John N. Allan
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA
| | - Chaitra Ujjani
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
| | - Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Hematology and Oncology, University of Washington, Seattle, WA
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Tam C, Thompson PA. BTK inhibitors in CLL: second-generation drugs and beyond. Blood Adv 2024; 8:2300-2309. [PMID: 38478390 PMCID: PMC11117011 DOI: 10.1182/bloodadvances.2023012221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/01/2024] [Indexed: 05/15/2024] Open
Abstract
ABSTRACT BTK inhibitors (BTKis) are established standards of care in multiple B-cell malignancies including chronic lymphocytic leukemia, mantle cell lymphoma, and Waldenstrom macroglobulinemia. The first-generation BTKi ibrutinib demonstrated superiority over standard chemoimmunotherapy regimens in multiple randomized trials but is limited by cardiovascular side effects such as atrial fibrillation and hypertension. Second-generation BTKis have improved selectivity and demonstrate reduced rates of cardiovascular complications in 3 head-to-head ibrutinib studies. The emergence of BTK C481S mutation has led to the development of noncovalent, "reversible" BTKis, such as pirtobrutinib, which are agnostic to the C481S mutation. However, these inhibitors are associated with resistant mutations outside the C481 hot spot. These variant non-C481 mutations are of great clinical interest because some are shared among pirtobrutinib, zanubrutinib, and acalabrutinib, with potential implications for cross resistance and treatment sequencing. Finally, BTK protein degraders with in vitro activity against C481 and non-C481 mutations are currently in clinical development. Here, we review the evolution of therapeutic BTK-targeting and discuss future directions for clinical research.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Haematology, Monash University, Melbourne, VIC, Australia
| | - Philip A Thompson
- Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Clinical Oncology, The University of Melbourne, Melbourne, VIC, Australia
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5
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Tham K, Prelewicz S, deHoll S, Stephens DM, Gomez CA. Infectious complications among patients receiving ibrutinib for the treatment of hematological malignancies. Am J Health Syst Pharm 2024; 81:112-119. [PMID: 37675967 DOI: 10.1093/ajhp/zxad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Indexed: 09/08/2023] Open
Abstract
PURPOSE Ibrutinib is a Bruton's tyrosine kinase inhibitor used to treat multiple hematologic malignancies and graft-versus-host disease. Though less myelosuppressive than cytotoxic chemotherapy, increased infections, including invasive fungal infections (IFIs), have been reported with ibrutinib use. This study aimed to determine the characteristics and risk factors for infection associated with ibrutinib at our institution. METHODS Patients who received ibrutinib between June 2014 and August 2019 were included. Primary endpoints were the incidence of any infection and the incidence of serious infection (defined as hospitalization, parenteral antimicrobial therapy, or pneumonia regardless of hospitalization). Infection risk factors were assessed using logistic regression. RESULTS One hundred thirty-two patients were identified (78% male; median age, 71 years). The most common indications for ibrutinib were chronic lymphocytic leukemia (67%) and mantle cell lymphoma (12%). Infection and serious infection occurred in 94 (71%) and 47 (36%) patients, respectively; when pneumonia was excluded as a criterion for serious infection, the serious infection rate was 27%. The median time from ibrutinib initiation to first infection was 125 days. Prior allogeneic hematopoietic stem cell transplantation (allo-HSCT) (odds ratio [OR], 4.60; 95% CI, 1.22-17.4) and corticosteroid use (OR, 5.55; 95% CI, 1.52-20.3) were significant risk factors for serious infection. IFIs were diagnosed in 7 patients (5%): 5 had Pneumocystis jirovecii pneumonia and 2 were infected with invasive molds. CONCLUSION Serious infection and IFI rates are high but similar to those previously described. Risk factors for serious infection included allo-HSCT and corticosteroid use. Targeted antimicrobial prophylaxis should be evaluated in prospective studies in patients on ibrutinib to reduce serious infections and IFI.
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Affiliation(s)
- Kenneth Tham
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Stacy Prelewicz
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Sara deHoll
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Deborah M Stephens
- Division of Hematology and Hematologic Malignancies, Department of Medicine, Huntsman Cancer Institute at the University of Utah Health, Salt Lake City, UT, USA
| | - Carlos A Gomez
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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6
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Zygmunciak P, Robak T, Puła B. Treatment of Double-Refractory Chronic Lymphocytic Leukemia-An Unmet Clinical Need. Int J Mol Sci 2024; 25:1589. [PMID: 38338868 PMCID: PMC10855898 DOI: 10.3390/ijms25031589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Recent years have seen significant improvement in chronic lymphocytic leukemia (CLL) management. Targeting B-cell lymphoma (BCL-2) and Bruton's kinase (BTK) have become the main strategies to restrain CLL activity. These agents are generally well tolerated, but the discontinuation of these therapies happens due to resistance, adverse effects, and Richter's transformation. A growing population of patients who have previously used both BTK inhibitors and BCL2 suffer from the constriction of the following regimens. This review explores the resistance mechanisms for both ibrutinib and venetoclax. Moreover, we present innovative approaches evaluated for treating double-refractory CLL.
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Affiliation(s)
- Przemysław Zygmunciak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (P.Z.); (B.P.)
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, 93-510 Lodz, Poland
- Department of General Hematology, Copernicus Memorial Hospital, 93-510 Lodz, Poland
| | - Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland; (P.Z.); (B.P.)
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7
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Allouchery M, Brunet K, Tomowiak C, Singier A, Pambrun E, Pariente A, Bezin J, Pérault-Pochat MC, Salvo F. Invasive fungal infection incidence and risk factors in patients receiving ibrutinib in real-life settings: A nationwide population-based cohort study. Mycoses 2024; 67:e13676. [PMID: 37984556 DOI: 10.1111/myc.13676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Data on the risk of invasive fungal infections (IFI) with ibrutinib treatment are scarce. OBJECTIVES This study aimed to determine IFI incidence and risk factors in ibrutinib-treated patients in real-life settings. METHODS We constituted a cohort of ibrutinib incident users in the French National Healthcare Database. All patients ≥18 years with a first dispensing of ibrutinib between 21 November 2014 and 31 December 2019 were included. Patients were followed from the cohort entry date until IFI, ibrutinib discontinuation, death, or 31 December 2020, whichever came first. The cumulative incidence function method was used to estimate the probability of IFI accounting for competing risk of death. A multivariate cause-specific Cox proportional hazards model was used to assess independent IFI risk factors. RESULTS Among 6937 ibrutinib-treated patients, 1-year IFI cumulative incidence was 1.3%, with invasive aspergillosis being the most frequent. Allogenic or autologous stem cell transplantation (ASCT) (hazard ratio [HR] 3.59, 95% confidence interval [1.74; 7.41]), previous anticancer treatment (HR 2.12, CI 95% [1.34; 3.35]) and chronic respiratory disease (HR 1.66, [1.03; 2.67]) were associated with higher risk of IFI. Besides neutropenia and corticosteroids, use of anti-CD20 agents was significantly more frequent in patients having experienced IFI (HR 3.68, [1.82; 7.45]). CONCLUSIONS In addition to patients with ASCT history, severe neutropenia or treated with corticosteroids, our findings support active surveillance of IFIs in those with chronic respiratory disease, previously treated, or treated with anti-CD20 agents in combination with ibrutinib. Further studies are needed to optimise IFI prophylaxis in these patient subgroups.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Kévin Brunet
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- INSERM U1070 PHAR2, Université de Poitiers, Poitiers, France
- Laboratoire de Parasitologie et Mycologie Médicale, CHU de Poitiers, Poitiers, France
| | - Cécile Tomowiak
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Allison Singier
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Elodie Pambrun
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Julien Bezin
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie médicale, Bordeaux, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM, UMR1084, Université de Poitiers, Poitiers, France
| | - Francesco Salvo
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie médicale, Bordeaux, France
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8
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López-Oreja I, Gohr A, Playa-Albinyana H, Giró A, Arenas F, Higashi M, Tripathi R, López-Guerra M, Irimia M, Aymerich M, Valcárcel J, Bonnal S, Colomer D. SF3B1 mutation-mediated sensitization to H3B-8800 splicing inhibitor in chronic lymphocytic leukemia. Life Sci Alliance 2023; 6:e202301955. [PMID: 37562845 PMCID: PMC10415613 DOI: 10.26508/lsa.202301955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023] Open
Abstract
Splicing factor 3B subunit 1 (SF3B1) is involved in pre-mRNA branch site recognition and is the target of antitumor-splicing inhibitors. Mutations in SF3B1 are observed in 15% of patients with chronic lymphocytic leukemia (CLL) and are associated with poor prognosis, but their pathogenic mechanisms remain poorly understood. Using deep RNA-sequencing data from 298 CLL tumor samples and isogenic SF3B1 WT and K700E-mutated CLL cell lines, we characterize targets and pre-mRNA sequence features associated with the selection of cryptic 3' splice sites upon SF3B1 mutation, including an event in the MAP3K7 gene relevant for activation of NF-κB signaling. Using the H3B-8800 splicing modulator, we show, for the first time in CLL, cytotoxic effects in vitro in primary CLL samples and in SF3B1-mutated isogenic CLL cell lines, accompanied by major splicing changes and delayed leukemic infiltration in a CLL xenotransplant mouse model. H3B-8800 displayed preferential lethality towards SF3B1-mutated cells and synergism with the BCL2 inhibitor venetoclax, supporting the potential use of SF3B1 inhibitors as a novel therapeutic strategy in CLL.
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Affiliation(s)
- Irene López-Oreja
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain
- Hematopathology Section, Department of Pathology, Hospital Clínic, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
| | - André Gohr
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Heribert Playa-Albinyana
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
| | - Ariadna Giró
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Fabian Arenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
| | - Morihiro Higashi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Rupal Tripathi
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Mònica López-Guerra
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hematopathology Section, Department of Pathology, Hospital Clínic, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
| | - Manuel Irimia
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Marta Aymerich
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hematopathology Section, Department of Pathology, Hospital Clínic, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
| | - Juan Valcárcel
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
| | - Sophie Bonnal
- Centre for Genomic Regulation, The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Dolors Colomer
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hematopathology Section, Department of Pathology, Hospital Clínic, Barcelona, Spain
- Centro de Investigación Biomédica en Red en Oncologia, Madrid, Spain
- Universitat Barcelona, Barcelona, Spain
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9
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Andersson ML, Johansson H, Österborg A, Månsson-Broberg A, Hansson L, Palma M. Incidence of cardiovascular and bleeding events and reasons for discontinuation in patients with chronic lymphocytic leukemia treated with ibrutinib-A retrospective analysis on consecutive patients from a well-defined region. Eur J Haematol 2023; 111:748-756. [PMID: 37565648 DOI: 10.1111/ejh.14072] [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: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Ibrutinib treatment is associated with cardiovascular side effects, in particular atrial fibrillation (AF) and hypertension, as well as increased risk of bleeding. Here, we aimed at describing the incidence of these events during long-term follow-up in patients with chronic lymphocytic leukemia treated outside clinical trials as well as identifying clinical factors predictive of developing AF. Additionally, other reasons for treatment withdrawal were analyzed. METHODS The study was retrospective, data were collected from medical records. RESULTS A total of 134 patients were identified. Median follow-up was 32 months (range 3-103) and median duration of ibrutinib treatment was 26 months (range 1-103). Of 110 patients with no prior history of AF, 24.5% were diagnosed during treatment. Newly diagnosed or worsening of pre-existing hypertension occurred in 15.7%. Sixty-six % of the patients experienced bleeding events, of which 7.5% grade 3-4. Treatment discontinuation and dose reduction occurred in 68% and 47% of the patients, respectively, mostly due to toxicity. CONCLUSIONS The incidence of AF was high and at a median follow-up of 2.5 years, two-thirds of the patients discontinued treatment mostly due to bleeding and infections. Treatment-related toxicity of any grade should be regarded as a concern of prolonged ibrutinib therapy.
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Affiliation(s)
- Maria L Andersson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Månsson-Broberg
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Hansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Marzia Palma
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
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10
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Qi J, Endres S, Yosifov DY, Tausch E, Dheenadayalan RP, Gao X, Müller A, Schneider C, Mertens D, Gierschik P, Wist M, Jebaraj BMC, Stilgenbauer S. Acquired BTK mutations associated with resistance to noncovalent BTK inhibitors. Blood Adv 2023; 7:5698-5702. [PMID: 36661329 PMCID: PMC10539862 DOI: 10.1182/bloodadvances.2022008955] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/19/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Affiliation(s)
- Jialei Qi
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Sascha Endres
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University, Ulm, Germany
| | | | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | | | - Xiang Gao
- Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Annika Müller
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Christof Schneider
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Daniel Mertens
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
- Cooperation Unit “Mechanisms of Leukemogenesis”, German Cancer Research Center, Heidelberg, Germany
| | - Peter Gierschik
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University, Ulm, Germany
| | - Martin Wist
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, Ulm University, Ulm, Germany
| | | | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
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11
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Allouchery M, Tomowiak C, Singier A, Puyade M, Dari L, Pambrun E, Pariente A, Bezin J, Pérault-Pochat MC, Salvo F. Bleeding risk with concurrent use of anticoagulants and ibrutinib: A population-based nested case-control study. Br J Haematol 2023; 203:311-318. [PMID: 37485683 DOI: 10.1111/bjh.18995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/22/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
Data regarding the safety of co-administration of ibrutinib with anticoagulants in real-life settings are scarce. Using a nationwide database, we conducted a nested case-control study in a cohort of new users of ibrutinib to assess the risk of clinically relevant bleeding (CRB) associated with anticoagulation. Cases were patients with a diagnosis of CRB, defined as hospitalization with a diagnosis of bleeding. The date of CRB constituted the index date. Up to four controls were matched on sex, age at index date and duration of follow-up. The risk of CRB associated with anticoagulation in patients receiving ibrutinib was estimated using conditional logistic regression models, providing odds ratios (OR) adjusted for risk factors of bleeding. Among 614 cases and 2407 matched controls, the risk of CRB was significantly higher in patients receiving both ibrutinib and anticoagulants (adjusted OR [aOR] 2.54, confidence interval [CI] 95% [1.94; 3.32]). When considering anticoagulant class, aOR was 1.99 (CI 95% [1.19; 3.33]) for VKA, 2.48 (CI 95% [1.76; 3.47]) for direct oral anticoagulants and 3.40 (CI 95% [2.01; 5.75]) for parenteral anticoagulants. In conclusion, this study found a 2.5-fold increased risk of CRB in patients receiving both ibrutinib and anticoagulants in real-life settings, and similar aOR among oral anticoagulants.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Faculté de Médecine, Université de Poitiers, Poitiers, France
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Cécile Tomowiak
- Onco-Hématologie et Thérapie Cellulaire, CHU de Poitiers, Poitiers, France
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
| | - Allison Singier
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Mathieu Puyade
- INSERM CIC 1402, CHU de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, CHU de Poitiers, Poitiers, France
| | - Loubna Dari
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- Médecine Vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Elodie Pambrun
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Antoine Pariente
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
| | - Julien Bezin
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie Médicale, Bordeaux, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, CHU de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM, UMR1084, Université de Poitiers, Poitiers, France
| | - Francesco Salvo
- Univ. Bordeaux, INSERM, BPH, U1219, Team AHeaD, Bordeaux, France
- CHU de Bordeaux, Pôle de Santé Publique, Service de Pharmacologie Médicale, Bordeaux, France
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12
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Aghel N, Baro Vila RC, Lui M, Hillis C, Leong DP. Diagnosis and Management of Cardiovascular Effects of Bruton's Tyrosine Kinase Inhibitors. Curr Cardiol Rep 2023; 25:941-958. [PMID: 37498449 DOI: 10.1007/s11886-023-01916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE OF REVIEW Bruton's tyrosine kinase inhibitors (BTKis) have changed the treatment and prognosis of several B-cell malignancies. However, since the approval of the first BTKi, ibrutinib, reports of cardiovascular adverse events especially atrial fibrillation have arisen. In this review, we discuss the cardiovascular side effects of BTKis and the management of these toxicities in clinical practice. RECENT FINDINGS BTKIs increase the risks of atrial fibrillation, bleeding, hypertension, heart failure, and potentially ventricular arrhythmia. Newer second and third-generation BTKis appear to have a lower risk of cardiovascular adverse events; however, long-term follow-up data are not available for these new BTKis. BTKis are an effective treatment for some B-cell malignancies; however, they can cause cardiovascular side effects. The best preventive strategies to minimize cardiovascular complications remain undefined. Currently, a practical approach for managing patients receiving BTKis includes the management of cardiovascular risk factors and side effects of BTKis to prevent interruption of cancer treatment.
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Affiliation(s)
- Nazanin Aghel
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- McMaster University, Hamilton, ON, Canada.
| | - Rocio C Baro Vila
- McMaster University, Hamilton, ON, Canada
- Division of Cardiology, Instituto Cardiovascular de Buenos Aires ICBA, Buenos Aires, Argentina
| | | | | | - Darryl P Leong
- The Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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13
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Seymour JF, Byrd JC, Ghia P, Kater AP, Chanan-Khan A, Furman RR, O'Brien S, Brown JR, Munir T, Mato A, Stilgenbauer S, Bajwa N, Miranda P, Higgins K, John E, de Borja M, Jurczak W, Woyach JA. Detailed safety profile of acalabrutinib vs ibrutinib in previously treated chronic lymphocytic leukemia in the ELEVATE-RR trial. Blood 2023; 142:687-699. [PMID: 37390310 PMCID: PMC10644206 DOI: 10.1182/blood.2022018818] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 04/19/2023] [Accepted: 04/23/2023] [Indexed: 07/02/2023] Open
Abstract
ELEVATE-RR demonstrated noninferior progression-free survival and lower incidence of key adverse events (AEs) with acalabrutinib vs ibrutinib in previously treated chronic lymphocytic leukemia. We further characterize AEs of acalabrutinib and ibrutinib via post hoc analysis. Overall and exposure-adjusted incidence rate was assessed for common Bruton tyrosine kinase inhibitor-associated AEs and for selected events of clinical interest (ECIs). AE burden scores based on previously published methodology were calculated for AEs overall and selected ECIs. Safety analyses included 529 patients (acalabrutinib, n = 266; ibrutinib, n = 263). Among common AEs, incidences of any-grade diarrhea, arthralgia, urinary tract infection, back pain, muscle spasms, and dyspepsia were higher with ibrutinib, with 1.5- to 4.1-fold higher exposure-adjusted incidence rates. Incidences of headache and cough were higher with acalabrutinib, with 1.6- and 1.2-fold higher exposure-adjusted incidence rate, respectively. Among ECIs, incidences of any-grade atrial fibrillation/flutter, hypertension, and bleeding were higher with ibrutinib, as were exposure-adjusted incidence rates (2.0-, 2.8-, and 1.6-fold, respectively); incidences of cardiac events overall (the Medical Dictionary for Regulatory Activities system organ class) and infections were similar between arms. Rate of discontinuation because of AEs was lower for acalabrutinib (hazard ratio, 0.62; 95% confidence interval, 0.41-0.93). AE burden score was higher for ibrutinib vs acalabrutinib overall and for the ECIs atrial fibrillation/flutter, hypertension, and bleeding. A limitation of this analysis is its open-label study design, which may influence the reporting of more subjective AEs. Overall, event-based analyses and AE burden scores demonstrated higher AE burden overall and specifically for atrial fibrillation, hypertension, and hemorrhage with ibrutinib vs acalabrutinib. This trial was registered at www.clinicaltrials.gov as #NCT02477696.
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Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - John C Byrd
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paolo Ghia
- Division of Experimental Oncology, Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milano, Italy
| | - Arnon P Kater
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Richard R Furman
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California-Irvine, Irvine, CA
| | | | - Talha Munir
- Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - Anthony Mato
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | | | | | | | | | | | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Krakow, Poland
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14
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Wang CM, Liu H, Li LJ, Song J, Wang HQ, Wu YH, Guan J, Xing LM, Wang GJ, Liu H, Qu W, Wang XM, Shao ZH, Fu R. [Analysis of infection in B-cell lymphoma patients treated with BTK inhibitors]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:582-586. [PMID: 37749040 PMCID: PMC10509625 DOI: 10.3760/cma.j.issn.0253-2727.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Indexed: 09/27/2023]
Affiliation(s)
- C M Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L J Li
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Song
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Q Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Y H Wu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - J Guan
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - L M Xing
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - G J Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - H Liu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - W Qu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - X M Wang
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Z H Shao
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - R Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin 300052, China
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15
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Bonfiglio S, Sutton LA, Ljungström V, Capasso A, Pandzic T, Weström S, Foroughi-Asl H, Skaftason A, Gellerbring A, Lyander A, Gandini F, Gaidano G, Trentin L, Bonello L, Reda G, Bödör C, Stavroyianni N, Tam CS, Marasca R, Forconi F, Panayiotidis P, Ringshausen I, Jaksic O, Frustaci AM, Iyengar S, Coscia M, Mulligan SP, Ysebaert L, Strugov V, Pavlovsky C, Walewska R, Österborg A, Cortese D, Ranghetti P, Baliakas P, Stamatopoulos K, Scarfò L, Rosenquist R, Ghia P. BTK and PLCG2 remain unmutated in one-third of patients with CLL relapsing on ibrutinib. Blood Adv 2023; 7:2794-2806. [PMID: 36696464 PMCID: PMC10279547 DOI: 10.1182/bloodadvances.2022008821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/07/2022] [Accepted: 01/01/2023] [Indexed: 01/26/2023] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) progressing on ibrutinib constitute an unmet need. Though Bruton tyrosine kinase (BTK) and PLCG2 mutations are associated with ibrutinib resistance, their frequency and relevance to progression are not fully understood. In this multicenter retrospective observational study, we analyzed 98 patients with CLL on ibrutinib (49 relapsing after an initial response and 49 still responding after ≥1 year of continuous treatment) using a next-generation sequencing (NGS) panel (1% sensitivity) comprising 13 CLL-relevant genes including BTK and PLCG2. BTK hotspot mutations were validated by droplet digital polymerase chain reaction (ddPCR) (0.1% sensitivity). By integrating NGS and ddPCR results, 32 of 49 relapsing cases (65%) carried at least 1 hotspot BTK and/or PLCG2 mutation(s); in 6 of 32, BTK mutations were only detected by ddPCR (variant allele frequency [VAF] 0.1% to 1.2%). BTK/PLCG2 mutations were also identified in 6 of 49 responding patients (12%; 5/6 VAF <10%), of whom 2 progressed later. Among the relapsing patients, the BTK-mutated (BTKmut) group was enriched for EGR2 mutations, whereas BTK-wildtype (BTKwt) cases more frequently displayed BIRC3 and NFKBIE mutations. Using an extended capture-based panel, only BRAF and IKZF3 mutations showed a predominance in relapsing cases, who were enriched for del(8p) (n = 11; 3 BTKwt). Finally, no difference in TP53 mutation burden was observed between BTKmut and BTKwt relapsing cases, and ibrutinib treatment did not favor selection of TP53-aberrant clones. In conclusion, we show that BTK/PLCG2 mutations were absent in a substantial fraction (35%) of a real-world cohort failing ibrutinib, and propose additional mechanisms contributing to resistance.
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MESH Headings
- Humans
- Agammaglobulinaemia Tyrosine Kinase/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Drug Resistance, Neoplasm/genetics
- Piperidines
- Recurrence
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Affiliation(s)
- Silvia Bonfiglio
- Centre for Omics Sciences, IRCCS Ospedale San Raffaele, Milan, Italy
- Division of Experimental Oncology, B cell Neoplasia Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Lesley-Ann Sutton
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Viktor Ljungström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Antonella Capasso
- Strategic Research Program on CLL, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Tatjana Pandzic
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Simone Weström
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Hassan Foroughi-Asl
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Aron Skaftason
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anna Gellerbring
- Clinical Genomics Stockholm, Science for Life Laboratory, Solna, Sweden
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Anna Lyander
- Clinical Genomics Stockholm, Science for Life Laboratory, Solna, Sweden
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Francesca Gandini
- Division of Experimental Oncology, B cell Neoplasia Unit, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Livio Trentin
- Department of Medicine, Hematology and Clinical Immunology, University of Padua, Italy
| | - Lisa Bonello
- Molecular Pathology Unit, A.O.U Città della Salute e della Scienza, Torino, Italy
- Department of Molecular Biotechnologies and Health Sciences, Università di Torino, Italy
| | - Gianluigi Reda
- Department of Hematology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Csaba Bödör
- HCEMM-SU Molecular Oncohematology Research Group, Budapest, Hungary
- 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Niki Stavroyianni
- Department of Hematology and HCT Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - Constantine S. Tam
- Department of Hematology, Alfred Health, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Roberto Marasca
- Department of Medical and Surgical Sciences, Hematology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Forconi
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Department of Hematology, University Hospital National Health Service Trust, Southampton, United Kingdom
| | - Panayiotis Panayiotidis
- Department of Propaedeutic Internal Medicine, Laiko Hospital, University of Athens, Athens, Greece
| | - Ingo Ringshausen
- Department of Hematology, University of Cambridge, Cambridge, United Kingdom
| | | | - Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Sunil Iyengar
- Department of Haemato-Oncology, Royal Marsden Hospital, London, United Kingdom
| | - Marta Coscia
- Department of Molecular Biotechnologies and Health Sciences, Università di Torino, Italy
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Stephen P. Mulligan
- Department of Haematology, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Loïc Ysebaert
- Département d'Hématologie, Institut Universitaire du Cancer-Oncopole de Toulouse, Toulouse, France
| | | | | | - Renata Walewska
- Department of Molecular Pathology, University Hospitals Dorset, Bournemouth, United Kingdom
| | - Anders Österborg
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Diego Cortese
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pamela Ranghetti
- Division of Experimental Oncology, B cell Neoplasia Unit, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Panagiotis Baliakas
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Sweden
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
| | - Lydia Scarfò
- Division of Experimental Oncology, B cell Neoplasia Unit, IRCCS Ospedale San Raffaele, Milan, Italy
- Strategic Research Program on CLL, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Richard Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Paolo Ghia
- Division of Experimental Oncology, B cell Neoplasia Unit, IRCCS Ospedale San Raffaele, Milan, Italy
- Strategic Research Program on CLL, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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16
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Maher N, Mouhssine S, Matti BF, Alwan AF, Gaidano G. Treatment Refractoriness in Chronic Lymphocytic Leukemia: Old and New Molecular Biomarkers. Int J Mol Sci 2023; 24:10374. [PMID: 37373521 DOI: 10.3390/ijms241210374] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults. Despite its indolent clinical course, therapy refractoriness and disease progression still represent an unmet clinical need. Before the advent of pathway inhibitors, chemoimmunotherapy (CIT) was the commonest option for CLL treatment and is still widely used in areas with limited access to pathway inhibitors. Several biomarkers of refractoriness to CIT have been highlighted, including the unmutated status of immunoglobulin heavy chain variable genes and genetic lesions of TP53, BIRC3 and NOTCH1. In order to overcome resistance to CIT, targeted pathway inhibitors have become the standard of care for the treatment of CLL, with practice-changing results obtained through the inhibitors of Bruton tyrosine kinase (BTK) and BCL2. However, several acquired genetic lesions causing resistance to covalent and noncovalent BTK inhibitors have been reported, including point mutations of both BTK (e.g., C481S and L528W) and PLCG2 (e.g., R665W). Multiple mechanisms are involved in resistance to the BCL2 inhibitor venetoclax, including point mutations that impair drug binding, the upregulation of BCL2-related anti-apoptotic family members, and microenvironmental alterations. Recently, immune checkpoint inhibitors and CAR-T cells have been tested for CLL treatment, obtaining conflicting results. Potential refractoriness biomarkers to immunotherapy were identified, including abnormal levels of circulating IL-10 and IL-6 and the reduced presence of CD27+CD45RO- CD8+ T cells.
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Affiliation(s)
- Nawar Maher
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Samir Mouhssine
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
| | - Bassam Francis Matti
- Department of Hematology and Bone Marrow Transplant, Hematology and Bone Marrow Transplant Center, Baghdad 00964, Iraq
| | - Alaa Fadhil Alwan
- Department of Clinical Hematology, The National Center of Hematology, Mustansiriyah University, Baghdad 10015, Iraq
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, 28100 Novara, Italy
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17
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Chen SS, Chiorazzi N. Functional consequences of inhibition of Bruton's tyrosine kinase by ibrutinib in chronic lymphocytic leukemia. Hematol Oncol 2023; 41 Suppl 1:119-128. [PMID: 37294973 DOI: 10.1002/hon.3144] [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: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
The leukemic B cells from patients with chronic lymphocytic leukemia (CLL) require interactions with non-malignant cells and matrix in the tissue microenvironment to survive and grow. These interactions are mediated through the B-cell antigen receptor (BCR), C-X-C chemokine receptor type 4 (CXCR4), and a variety of integrins, including VLA-4. Exciting each receptor type leads to activation of Bruton's tyrosine kinase (BTK), which in turn helps initiate trophic signals that prevent cell death and promote cell activation and growth as well as allowing cells to return to anatomic sites for rescue signals. These represent the two major functional actions targeted by inhibitors of Btk. Here we relate some of the therapeutic actions of ibrutinib, a Btk inhibitor that is extremely helpful for patients with CLL, certain Diffuse Large B-cell Lymphomas (ABC type), and other non-Hodgkin's lymphomas, emphasizing that ibrutinib's value results from blocking beneficial signals, not by inducing lethal ones.
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Affiliation(s)
- Shih-Shih Chen
- Karches Center for Oncology Research, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Nicholas Chiorazzi
- Karches Center for Oncology Research, The Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Departments of Molecular Medicine and of Medicine, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
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18
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Eyre TA, Riches JC. The Evolution of Therapies Targeting Bruton Tyrosine Kinase for the Treatment of Chronic Lymphocytic Leukaemia: Future Perspectives. Cancers (Basel) 2023; 15:cancers15092596. [PMID: 37174062 PMCID: PMC10177608 DOI: 10.3390/cancers15092596] [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: 03/22/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
The development of inhibitors of Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 (BCL2) has resulted in a paradigm shift in the treatment of chronic lymphocytic leukaemia (CLL) over the last decade. Observations regarding the importance of B-cell receptor signalling for the survival and proliferation of CLL cells led to the development of the first-in-class BTK inhibitor (BTKi), ibrutinib, for the treatment of CLL. Despite being better tolerated than chemoimmunotherapy, ibrutinib does have side effects, some of which are due to the off-target inhibition of kinases other than BTK. As a result, more specific inhibitors of BTK were developed, such as acalabrutinib and zanubrutinib, which have demonstrated equivalent/enhanced efficacy and improved tolerability in large randomized clinical trials. Despite the increased specificity for BTK, side effects and treatment resistance remain therapeutic challenges. As these drugs all bind covalently to BTK, an alternative approach was to develop noncovalent inhibitors of BTK, including pirtobrutinib and nemtabrutinib. The alternative mechanisms of BTK-binding of these agents has the potential to overcome resistance mutations, something that has been borne out in early clinical trial data. A further step in the clinical development of BTK inhibition has been the introduction of BTK degraders, which remove BTK by ubiquitination and proteasomal degradation, in marked contrast to BTK inhibition. This article will review the evolution of BTK inhibition for CLL and offer future perspectives on the sequencing of an increasing number of different agents, and how this may be impacted on by mutations in BTK itself and other kinases.
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Affiliation(s)
- Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Headington, Oxford OX3 7LE, UK
| | - John C Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, UK
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19
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Khelifi RS, Huang SJ, Savage KJ, Villa D, Scott DW, Ramadan K, Connors JM, Sehn LH, Toze CL, Gerrie AS. Population-level impact of ibrutinib for chronic lymphocytic leukemia in British Columbia, Canada. Leuk Lymphoma 2023:1-10. [PMID: 37086469 DOI: 10.1080/10428194.2023.2199340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2023]
Abstract
Ibrutinib has dramatically changed the treatment landscape for chronic lymphocytic leukemia (CLL) since its availability in British Columbia (BC), Canada in 2014. We analyzed patterns of use and real-world survival outcomes in 370 patients who received ibrutinib for first-line (1 L, n = 35) and relapsed/refractory (R/R, n = 335) CLL between 2014-2018 in BC. Dose reductions and interruptions were frequent in 32% and 27%, respectively. With a median follow-up of 27.6 months, 35% of patients discontinued ibrutinib, primarily for adverse events (AEs) rather than progressive disease. Over the course of treatment, 87% of patients experienced at least one adverse event. The 2-year overall survival (OS) and event-free survival (EFS) were excellent at 83.9% and 76.1%, respectively, with medians not reached. However, patients who discontinued ibrutinib had a median OS of 32.5 months and median EFS of only 3.8 months from time of discontinuation, highlighting the need to minimize toxicity in the real-world.
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Affiliation(s)
- Rania S Khelifi
- Department of Experimental Medicine, University of British Columbia, Vancouver, Canada
| | - Steven J Huang
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
| | - Kerry J Savage
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Diego Villa
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - David W Scott
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Khaled Ramadan
- St. Paul's Hospital, Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Joseph M Connors
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Laurie H Sehn
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Cynthia L Toze
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
| | - Alina S Gerrie
- Department of Experimental Medicine, University of British Columbia, Vancouver, Canada
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
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20
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Chung C, Umoru G, Abboud K, Hobaugh E. Sequencing and combination of current small-molecule inhibitors for chronic lymphocytic leukemia: Where is the evidence? Eur J Haematol 2023. [PMID: 37037657 DOI: 10.1111/ejh.13973] [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: 12/02/2022] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/12/2023]
Abstract
Small-molecule inhibitors have revolutionized the treatment of chronic lymphocytic leukemia (CLL), a landscape once dominated by chemoimmunotherapy (i.e., an anti-CD20 monoclonal antibody in combination with systemic chemotherapy) in fit and unfit individuals. Key challenges include the management of refractory disease as well as the optimization of the therapy sequence. Decreased responsiveness has been observed with prolonged treatment, especially with Bruton tyrosine kinase (BTK) and phosphatidylinositol 3-kinase (PI3K) inhibitors which are given continuously, while venetoclax, an agent that targets dysregulations in intrinsic apoptosis signaling, has a fixed duration when combined with anti-CD20 monoclonal antibodies or BTK inhibitors. Combination therapy aims to synergistically target different oncogenic signaling pathways to abrogate the proliferation of resistant clones and thereby allows for fixed-duration treatments. An advantage of fixed-duration therapy is the potential to decrease financial and drug-induced toxicities. Sequencing of therapies is important to individualize treatment decisions based on factors such as age, comorbidities, tolerability, and patient preferences. However, to date, there are limited data to guide the rational sequencing or combination of these therapies, since conventional chemoimmunotherapy or chemotherapy regimens were used as comparators against these small-molecule inhibitors in trials that led to their regulatory approvals. In this article, we examined and evaluated the current evidence for sequencing versus the combination of small-molecule inhibitors for CLL by conducting comprehensive searches of the United States National Library of Medicine PubMed database, key meeting abstracts, and clinical practice guidelines. We also summarized findings from expert opinions to elucidate best practices for clinical scenarios with limited evidence to guide treatment selection.
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Affiliation(s)
- Clement Chung
- Houston Methodist West Hospital, Houston, Texas, USA
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21
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Hampel PJ, Parikh SA. BTKi bonanza in CLL/SLL: Sorting out the differences. Am J Hematol 2023; 98:556-559. [PMID: 36691752 DOI: 10.1002/ajh.26859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023]
Affiliation(s)
- Paul J Hampel
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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22
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Xu W, Zhou K, Wang T, Yang S, Liu L, Hu Y, Zhang W, Ding K, Zhou J, Gao S, Xu B, Zhu Z, Liu T, Zhang H, Hu J, Ji C, Wang S, Xia Z, Wang X, Li Y, Song Y, Ma S, Tang X, Zhang B, Li J. Orelabrutinib in relapsed or refractory chronic lymphocytic leukemia/small lymphocytic lymphoma patients: Multi-center, single-arm, open-label, phase 2 study. Am J Hematol 2023; 98:571-579. [PMID: 36683422 DOI: 10.1002/ajh.26826] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/05/2022] [Accepted: 12/21/2022] [Indexed: 01/24/2023]
Abstract
Orelabrutinib is a novel, small molecule, selective irreversible Bruton's tyrosine kinase inhibitor. The aim of this study was to evaluate the efficacy and safety in patients with refractory or relapsed chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). This is single-arm, multi-center, open-label, phase 2 study in 80 eligible Chinese patients, who were treated with monotherapy of orelabrutinib at 150 mg once daily. Overall response rate evaluated by an independent review committee was the primary endpoint, and secondary endpoints include progression-free survival, overall survival, and safety. Independent review committee assessed overall response rate was 92.5% (74/80); complete response 21.3% (17/80), partial response 60.0% (48/80), partial response with lymphocytosis 11.3% (9/80). At a 32.3-month median follow-up, the median progression-free survival had not been achieved, while the 30-month progression-free survival rate and overall survival rates were 70.9% (95% confidence interval [CI], 59.5-79.6) and 81.3% (95% CI, 70.8-88.2), respectively. Orelabrutinib also revealed substantial response in patients with high prognostic risks: overall response rates of patients carrying positive TP53 mutational status or del(17p), del(11q), as well as unmutated immunoglobulin heavy-chain variable region gene were 100%, 94.7%, and 93.9%, respectively. Most adverse events were in low grade, with 86.8% of AEs being Grade 1 or 2. Nearly 67% of patients were still receiving orelabrutinib after almost a 3-year follow-up. In conclusion, Orelabrutinib demonstrated compelling efficacy as well as safety profiles, with a noteworthy number of patients obtaining complete response in refractory or relapsed CLL/SLL.
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Affiliation(s)
- Wei Xu
- Department of Hematology, Pukou CLL Center, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People's Republic of China
| | - Keshu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Tingyu Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, People's Republic of China
| | - Shenmiao Yang
- Department of Hematology, Peking University People's Hospital, Beijing, People's Republic of China
| | - Lihong Liu
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, People's Republic of China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Wei Zhang
- Department of Hematology, Peking Union Medical College Hospital, Beijing, People's Republic of China
| | - Kaiyang Ding
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, People's Republic of China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Sujun Gao
- Department of Hematology, The First Hospital, Jilin University, Jilin, People's Republic of China
| | - Bing Xu
- Department of Hematology, The First Affiliated Hospital of Xiamen University, Xiamen, People's Republic of China
| | - Zunmin Zhu
- Institute of Hematology, Henan Provincial People's Hospital, Zhengzhou, People's Republic of China
| | - Ting Liu
- Department of Hematology, West China Hospital of Sichuan University, Chengdu, People's Republic of China
| | - Huilai Zhang
- Lymphoma, Tianjin Medical University Cancer Institute & Hospital, Tianjin, People's Republic of China
| | - Jianda Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, People's Republic of China
| | - Chunyan Ji
- Department of Hematology, Qilu Hospital, Shandong University Jinan, Jinan, People's Republic of China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, Guangzhou, People's Republic of China
| | - Zhongjun Xia
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yatsen University Cancer Center, Guangzhou, People's Republic of China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Jinan, People's Republic of China
| | - Yan Li
- Department of Hematology, The First Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Yongping Song
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, People's Republic of China
| | - Shuo Ma
- Department of Clinical Development, InnoCare Pharma Limited, Beijing, People's Republic of China
| | - Xinran Tang
- Department of Clinical Development, InnoCare Pharma Limited, Beijing, People's Republic of China
| | - Bin Zhang
- Department of Clinical Development, InnoCare Pharma Limited, Beijing, People's Republic of China
| | - Jianyong Li
- Department of Hematology, Pukou CLL Center, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, People's Republic of China
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23
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Shadman M, Manzoor BS, Sail K, Tuncer HH, Allan JN, Ujjani C, Emechebe N, Kamalakar R, Coombs CC, Leslie L, Barr PM, Brown JR, Eyre TA, Rampotas A, Schuh A, Lamanna N, Skarbnik A, Roeker LE, Bannerji R, Eichhorst B, Fleury I, Davids MS, Alhasani H, Jiang D, Hill BT, Schuster SJ, Brander DM, Pivneva I, Burne R, Guerin A, Mato AR. Treatment Discontinuation Patterns for Patients With Chronic Lymphocytic Leukemia in Real-World Settings: Results From a Multi-Center International Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023:S2152-2650(23)00107-6. [PMID: 37076367 DOI: 10.1016/j.clml.2023.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 04/21/2023]
Abstract
INTRODUCTION This study assessed treatment discontinuation patterns and reasons among chronic lymphocytic leukemia (CLL) patients initiating first-line (1L) and second-line (2L) treatments in real-world settings. MATERIALS AND METHODS Using deidentified electronic medical records from the CLL Collaborative Study of Real-World Evidence, premature treatment discontinuation was assessed among FCR, BR, BTKi-based, and BCL-2-based regimen cohorts. RESULTS Of 1364 1L patients (initiated in 1997-2021), 190/13.9% received FCR (23.7% discontinued prematurely); 255/18.7% received BR (34.5% discontinued prematurely); 473/34.7% received BTKi-based regimens, of whom 28.1% discontinued prematurely; and 43/3.2% received venetoclax-based regimens, of whom 16.3% discontinued prematurely (venetoclax monotherapy: 7/0.5%, of whom 42.9% discontinued; VG/VR: 36/2.6%, of whom 11.1% discontinued). The most common reasons for treatment discontinuation were adverse events (FCR: 25/13.2%; BR: 36/14.1%; BTKi-based regimens: 75/15.9%) and disease progression (venetoclax-based: 3/7.0%). Of 626 2L patients, 20/3.2% received FCR (50.0% discontinued); 62/9.9% received BR (35.5% discontinued); 303/48.4% received BTKi-based regimens, of whom 38.0% discontinued; and 73/11.7% received venetoclax-based regimens, of whom 30.1% discontinued (venetoclax monotherapy: 27/4.3%, of whom 29.6% discontinued; VG/VR: 43/6.9%, of whom 27.9% discontinued). The most common reasons for treatment discontinuation were adverse events (FCR: 6/30.0%; BR: 11/17.7%; BTKi-based regimens: 60/19.8%; venetoclax-based: 6/8.2%). CONCLUSION The findings of this study highlight the continued need for tolerable therapies in CLL, with finite therapy offering a better tolerated option for patients who are newly diagnosed or relapsed/refractory to prior treatments.
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Affiliation(s)
- Mazyar Shadman
- Fred Hutch Cancer Center and University of Washington, Seattle, WA
| | | | | | - Hande H Tuncer
- The Cancer Center at Lowell General Hospital, Lowell, MA
| | | | - Chaitra Ujjani
- Fred Hutch Cancer Center and University of Washington, Seattle, WA
| | | | | | - Catherine C Coombs
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lori Leslie
- John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | - Toby A Eyre
- Churchill Hospital, Oxford University, Oxford, UK
| | | | - Anna Schuh
- Churchill Hospital, Oxford University, Oxford, UK
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | | | - Lindsey E Roeker
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rajat Bannerji
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Barbara Eichhorst
- Department of Internal Medicine, Center of Integrated Oncology Köln Bonn, University of Cologne, Cologne, Germany
| | | | | | | | | | | | - Stephen J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | | | - Anthony R Mato
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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24
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Iyer P, Wang L. Emerging Therapies in CLL in the Era of Precision Medicine. Cancers (Basel) 2023; 15:1583. [PMID: 36900373 PMCID: PMC10000606 DOI: 10.3390/cancers15051583] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Over the past decade, the treatment landscape of CLL has vastly changed from the conventional FC (fludarabine and cyclophosphamide) and FCR (FC with rituximab) chemotherapies to targeted therapies, including inhibitors of Bruton tyrosine kinase (BTK) and phosphatidylinositol 3-kinase (PI3K) as well as inhibitors of BCL2. These treatment options dramatically improved clinical outcomes; however, not all patients respond well to these therapies, especially high-risk patients. Clinical trials of immune checkpoint inhibitors (PD-1, CTLA4) and chimeric antigen receptor T (CAR T) or NK (CAR NK) cell treatment have shown some efficacy; still, long-term outcomes and safety issues have yet to be determined. CLL remains an incurable disease. Thus, there are unmet needs to discover new molecular pathways with targeted or combination therapies to cure the disease. Large-scale genome-wide whole-exome and whole-genome sequencing studies have discovered genetic alterations associated with disease progression, refined the prognostic markers in CLL, identified mutations underlying drug resistance, and pointed out critical targets to treat the disease. More recently, transcriptome and proteome landscape characterization further stratified the disease and revealed novel therapeutic targets in CLL. In this review, we briefly summarize the past and present available single or combination therapies, focusing on potential emerging therapies to address the unmet clinical needs in CLL.
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Affiliation(s)
- Prajish Iyer
- Department of Systems Biology, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Monrovia, CA 91007, USA
| | - Lili Wang
- Department of Systems Biology, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Monrovia, CA 91007, USA
- Toni Stephenson Lymphoma Center, Beckman Research Institute, City of Hope National Comprehensive Cancer Center, Duarte, CA 91016, USA
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25
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Xu W, Yang S, Zhou K, Pan L, Li Z, Gao S, Zhou D, Hu J, Feng R, Huang H, Wang T, Li D, Ji M, Guo H, Zhao X, Wu B, Yu Y, Wang Y, Huang J, Novotny W, Li J. Zanubrutinib in patients with relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma: final results and correlative analysis of lymphocytosis. Leuk Lymphoma 2023; 64:712-716. [PMID: 36799536 DOI: 10.1080/10428194.2022.2164692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Affiliation(s)
- Wei Xu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing, China
| | - Shenmiao Yang
- Peking University Peoples Hospital, Peking University Institute of Hematology, Beijing, China
| | - Keshu Zhou
- Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Ling Pan
- West China Hospital of Sichuan University, Chengdu, China
| | - Zengjun Li
- Blood Disease Hospital, Chinese Academy of Medical Science, Tianjin, China
| | - Sujun Gao
- The First Hospital of Jilin University, Changchun, China
| | - Daobin Zhou
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianda Hu
- Fujian Provincial Key Laboratory on Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ru Feng
- Nanfang Hospital of Southern Medical University, Guangzhou, China
| | - Haiwen Huang
- The First Hospital of Soochow University, Suzhou, China
| | - Tingyu Wang
- Blood Disease Hospital, Chinese Academy of Medical Science, Tianjin, China
| | - Dengju Li
- Tongji Hospital, Tongji Medical College, Wuhan, China
| | - Meng Ji
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Haiyi Guo
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Xia Zhao
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Binghao Wu
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Yiling Yu
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Yu Wang
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Jane Huang
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - William Novotny
- BeiGene (Beijing) Co., Ltd., Beijing, China
- BeiGene (Shanghai) Co., Ltd., Shanghai, China
- BeiGene USA, Inc., San Mateo, CA, USA
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Personalized Cancer Medicine, Nanjing, China
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26
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Chatterjee A, van de Wetering G, Goeree R, Owen C, Desbois AM, Barakat S, Manzoor BS, Sail K. A Probabilistic Cost-Effectiveness Analysis of Venetoclax and Obinutuzumab as a First-Line Therapy in Chronic Lymphocytic Leukemia in Canada. PHARMACOECONOMICS - OPEN 2023; 7:199-216. [PMID: 36334238 PMCID: PMC10043091 DOI: 10.1007/s41669-022-00375-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Venetoclax is a first-in-class targeted therapy option that is an inducer of apoptosis in chronic lymphocytic leukemia (CLL) cells. The open-label phase III CLL14 clinical trial showed that venetoclax combined with obinutuzumab (VEN+O) is superior to obinutuzumab combined with chlorambucil in newly diagnosed patients with CLL. The aim of this study was to assess the health economic value of VEN+O for the frontline treatment of CLL in Canada from a publicly funded healthcare system perspective. METHODS A partitioned survival analyses model was developed including three health states: progression free, progressed, and death. A cycle length of 28 days and a time horizon of 10 years was assumed. VEN+O treatment for a fixed duration of 12 months was compared to obinutuzumab combined with chlorambucil, fludarabine plus cyclophosphamide plus rituximab, bendamustine plus rituximab, chlorambucil plus rituximab, ibrutinib, and acalabrutinib. The population in the model included both unfit and overall frontline CLL patients, two subgroups were also assessed (patients with del17p/TP53 mutations and patients without del17p/TP53 mutations). Survival data extrapolated from the CLL14 trial were used to populate the model. Uncertainty was assessed via one-way sensitivity analyses, probabilistic analyses, and scenario analyses. RESULTS Based on the probabilistic analyses, unfit frontline CLL patients receiving VEN+O were estimated to incur costs of Canadian dollars ($) 217,727 [confidence interval (CI) $170,725, $300,761] (del17p/TP53: $209,102 [CI $159,698, $386,190], non-del17p/TP53: $217,732 [CI $171,232, $299,063]) and accrue 4.96 [CI 4.04, 5.82] quality-adjusted life-years (del17p/TP53: 3.11 [CI 2.00, 4.20], non-del17p/TP53: 5.04 [CI 4.05, 5.92]). Obinutuzumab combined with chlorambucil, bendamustine plus rituximab, chlorambucil plus rituximab, and ibrutinib accrued lower quality-adjusted life-years and higher costs and as such, VEN+O was the dominant treatment option. The full incremental analysis showed that acalabrutinib was more expensive and more efficacious compared with VEN+O with an incremental-cost-effectiveness-ratio of $2,139,180/quality-adjusted life-year versus VEN+O and not a cost-effective option in Canada. Probabilistic analyses show that at a willingness to pay of $50,000/quality-adjusted life-year gained, VEN+O has the greatest probability of being cost effective. CONCLUSIONS VEN+O is a cost-effective treatment option for unfit frontline CLL patients and provides value for money to healthcare payers.
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Affiliation(s)
| | | | - Ron Goeree
- Goeree Consulting Ltd., Mount Hope, ON, Canada
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Benedetti E, Baratè C, Mavilia F, Bramanti E, Morganti R, Guerri V, Cervetti G, Capochiani E, Bertaggia I, Stella SM, Traverso G, Bruno B, Galimberti S. Relapsed/Refractory Chronic Lymphocytic Leukemia Patients Treated with Fixed Duration Venetoclax-Rituximab: Assessment of Response with Ultrasound, and Relationship with Minimal Residual Disease. J Clin Med 2023; 12:jcm12051772. [PMID: 36902559 PMCID: PMC10003523 DOI: 10.3390/jcm12051772] [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: 12/12/2022] [Revised: 02/17/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
A fixed duration of venetoclax-rituximab (VenR) resulted in a significant benefit of both PFS and in the attainment of an undetectable minimal residual disease (uMRD) compared with bendamustine-rituximab in relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL) patients. The 2018 International Workshop on CLL guidelines, outside the context of clinical trials, suggested ultrasonography (US) as a possible imaging technique to evaluate visceral involvement, and palpation to evaluate superficial lymph nodes (SupLNs). In this real-life study we prospectively enrolled N = 22 patients. Patients were assessed by US, to determine nodal and splenic response in R/R CLL patients treated with a fixed duration VenR. We found an overall response rate, complete remission, partial remission, and stable disease, of 95.4%, 68%, 27.3%, and 4.5%, respectively. Responses were also correlated with risk categories. The time to response, and the time to clearance of the disease in the spleen, in abdominal LN (AbdLNs), and in SupLNs were discussed. Responses were independent from LN size. The correlation between response rate with MRD were also investigated. US allowed to detect a substantial CR rate correlated with uMRD.
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Affiliation(s)
- Edoardo Benedetti
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), 56100 Pisa, Italy
- Correspondence:
| | - Claudia Baratè
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Fabrizio Mavilia
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Emilia Bramanti
- Institute of Chemistry of Organometallic Compounds (ICCOM), Italian National Research Council (CNR), Via G Moruzzi 1, 56124 Pisa, Italy
| | - Riccardo Morganti
- Azienda Ospedaliero Universitaria Pisana, Section of Statistics, 56126 Pisa, Italy
| | - Valentina Guerri
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giulia Cervetti
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Enrico Capochiani
- Hematology Unit, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy
| | - Ilaria Bertaggia
- Hematology Unit, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy
| | | | - Ginevra Traverso
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Benedetto Bruno
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10126 Torino, Italy
| | - Sara Galimberti
- Azienda Ospedaliero Universitaria Pisana, Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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Hillmen P, Eichhorst B, Brown JR, Lamanna N, O'Brien SM, Tam CS, Qiu L, Kazmierczak M, Zhou K, Šimkovič M, Mayer J, Gillespie-Twardy A, Shadman M, Ferrajoli A, Ganly PS, Weinkove R, Grosicki S, Mital A, Robak T, Österborg A, Yimer HA, Salmi T, Ji M, Yecies J, Idoine A, Wu K, Huang J, Jurczak W. Zanubrutinib Versus Ibrutinib in Relapsed/Refractory Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma: Interim Analysis of a Randomized Phase III Trial. J Clin Oncol 2023; 41:1035-1045. [PMID: 36395435 PMCID: PMC9928683 DOI: 10.1200/jco.22.00510] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Zanubrutinib is a potent, irreversible next-generation Bruton tyrosine kinase (BTK) inhibitor designed to maximize BTK occupancy and minimize off-target kinase inhibition. We hypothesized that complete/sustained BTK occupancy may improve efficacy outcomes and increased BTK specificity may minimize off-target inhibition-related toxicities. PATIENTS AND METHODS ALPINE (ClinicalTrials.gov identifier: NCT03734016) is a global, randomized, open-label phase III study of zanubrutinib versus ibrutinib in patients with relapsed/refractory chronic lymphocytic leukemia. The primary end point was investigator-assessed overall response rate (ORR). The preplanned interim analysis was scheduled approximately 12 months after the first 415 patients were enrolled. RESULTS Between November 1, 2018, and December 14, 2020, 652 patients were enrolled. We present the interim analysis of the first 415 enrolled patients randomly assigned to receive zanubrutinib (n = 207) or ibrutinib (n = 208). At 15 months of median follow-up, ORR (partial or complete response) was significantly higher with zanubrutinib (78.3%; 95% CI, 72.0 to 83.7) versus ibrutinib (62.5%; 95% CI, 55.5 to 69.1; two-sided P < .001). ORR was higher with zanubrutinib versus ibrutinib in subgroups with del(17p)/TP53 mutations (80.5% v 50.0%) and del(11q) (83.6% v 69.1%); 12-month progression-free survival in all patients was higher with zanubrutinib (94.9%) versus ibrutinib (84.0%; hazard ratio, 0.40; 95% CI, 0.23 to 0.69). Atrial fibrillation rate was significantly lower with zanubrutinib versus ibrutinib (2.5% v 10.1%; two-sided P = .001). Rates of cardiac events, major hemorrhages, and adverse events leading to treatment discontinuation/death were lower with zanubrutinib. CONCLUSION Zanubrutinib had a significantly higher ORR, lower atrial fibrillation rate, and improved progression-free survival and overall cardiac safety profile versus ibrutinib. These data support improved efficacy/safety outcomes with selective BTK inhibition.
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Affiliation(s)
- Peter Hillmen
- St James's University Hospital, Leeds, United Kingdom,Peter Hillmen, MBChB, PhD, St James's University Hospital, Level 3, Bexley Wing, Beckett St, Leeds LS9 7TF, United Kingdom; e-mail:
| | - Barbara Eichhorst
- Department I of Internal Medicine, Center for Integrated Oncology Aachen, University of Cologne, Bonn, Cologne, Düsseldorf, Germany
| | - Jennifer R. Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
| | - Susan M. O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, CA
| | - Constantine S. Tam
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia,University of Melbourne, Parkville, Victoria, Australia,St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia,Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Hematological Disorders, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Maciej Kazmierczak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Keshu Zhou
- Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Martin Šimkovič
- 4th Department of Internal Medicine-Hematology, University Hospital, Hradec Kralove, Czech Republic,Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Mayer
- Department of Internal Medicine-Hematology and Oncology, Masaryk University and University Hospital, Brno, Czech Republic
| | | | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, WA,Department of Medicine, University of Washington, Seattle, WA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Peter S. Ganly
- Department of Haematology, Christchurch Hospital, Christchurch, New Zealand
| | - Robert Weinkove
- Wellington Blood and Cancer Centre, Capital and Coast District Health Board, Wellington, New Zealand,Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Health Sciences Faculty, Medical University of Silesia, Katowice, Poland
| | - Andrzej Mital
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Anders Österborg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Meng Ji
- BeiGene (Beijing) Co, Ltd, Beijing, China
| | | | | | | | | | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Krakow, Poland
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Moldovianu AM, Stoia R, Vasilica M, Ursuleac I, Badelita SN, Tomescu AA, Preda OD, Bardas A, Cirstea M, Coriu D. Real-World Clinical Outcomes and Adverse Events in Patients with Chronic Lymphocytic Leukemia Treated with Ibrutinib: A Single-Center Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020324. [PMID: 36837525 PMCID: PMC9959500 DOI: 10.3390/medicina59020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/28/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
Background and Objectives: The treatment of chronic lymphocytic leukemia (CLL) has acquired new targeted therapies. In clinical trials, ibrutinib improved outcomes safely. Real-world data called for a reappraisal of ibrutinib strategies. We report on a single center's experience with ibrutinib monotherapy, aiming to explore the outcomes, tolerability, and prognosis of CLL patients in routine clinical practice. Materials and Methods: Data were collected from all CLL patients treated with ibrutinib at Fundeni Clinical Institute, Bucharest, Romania, between January 2016 and June 2021. Results: A total of one hundred twenty-three CLL adult patients were treated with ibrutinib. Of the patients, 87% had relapsed/refractory CLL. The median age at ibrutinib initiation was 65 years; 44.7% of patients were staged Rai III/IV. At 32-month median follow-up, the median progression-free survival (PFS) was 50 months, the overall survival (OS) was not reached, and the overall response rate (ORR) was 86.2%. The age or number of previous therapies did not impact outcomes or tolerability. An Eastern Cooperative Oncology Group performance status (ECOG PS) score ≥ 2 and shorter time from initiation of last therapy (TILT) before ibrutinib predicted inferior PFS. Baseline characteristics had no impact on the OS except for TILT in R/R CLL patients. Drug-related adverse events (AEs) of any grade and grade ≥ 3 AEs were reported in 82.1% and 30.9% of the patients, respectively. Infections were the most common AEs (29.3%). Drug discontinuation was permanent in 43.9% of patients, mainly due to disease progression (17.1%) and toxicity (8.9%). Patients with a Cumulative Illness Rating Scale (CIRS) score ≥ 6 had a higher risk for toxicity-related discontinuation. An ECOG PS ≥ 2 predicted an increased rate of permanent discontinuation and grade ≥ 3 AEs. Conclusions: The outcomes of this study align with the results from ibrutinib clinical trials. Our study demonstrated that poor patient fitness, early relapse before ibrutinib, and permanent ibrutinib discontinuation are essential outcome determinants. Patient comorbidity burden and fitness were significant predictors for ibrutinib intolerance.
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Affiliation(s)
- Ana-Maria Moldovianu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Correspondence:
| | - Razvan Stoia
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mariana Vasilica
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Iulia Ursuleac
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Sorina Nicoleta Badelita
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Andra Alina Tomescu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Oana Diana Preda
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alexandru Bardas
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mihaela Cirstea
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Daniel Coriu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
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30
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Ryan CE, Brander DM, Barr PM, Tyekucheva S, Hackett LR, Collins MC, Fernandes SM, Ren Y, Zhou Y, McDonough MM, Walker HA, McEwan MR, Abramson JS, Jacobsen ED, LaCasce AS, Fisher DC, Brown JR, Davids MS. A phase 1b study of ibrutinib in combination with obinutuzumab in patients with relapsed or refractory chronic lymphocytic leukemia. Leukemia 2023; 37:835-842. [PMID: 36717653 DOI: 10.1038/s41375-023-01830-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/31/2023]
Abstract
This study investigated ibrutinib plus obinutuzumab in relapsed/refractory CLL, evaluating tolerability of 3 sequencing regimens as well as overall safety and efficacy. Fifty-two patients were initially randomized 1:1:1 to receive either obinutuzumab 1 month before ibrutinib initiation, ibrutinib 1 month prior to obinutuzumab initiation, or to start both drugs concomitantly. Higher rates of infusion-related reactions were observed with the first sequence, and only the latter 2 cohorts were expanded. Grade 4 hematologic toxicity was uncommon, and notable all-grade non-hematologic toxicities included bruising (58%), hypertension (46%), arthralgia (38%), diarrhea (37%), transaminitis (35%), atrial fibrillation (21%), and serious infection (17%). Best overall response rate was 96% (including 40% CR and 56% PR). Best rates of undetectable minimal residual disease in peripheral blood and bone marrow were 27% and 19%, respectively. With a median follow-up of 41.5 months, four-year progression-free and overall survival rates are 74% and 93%, respectively. Correlative studies demonstrated that serum CCL4 and CXCL13 levels were associated with clinical response, and BH3 profiling revealed increased BCL-2 and BCL-xL dependence in CLL cells from patients on treatment. Overall, ibrutinib plus obinutuzumab was highly active, with a manageable safety profile, supporting further investigation of this type of approach in relapsed/refractory CLL.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Durham, NC, USA
| | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Liam R Hackett
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mary C Collins
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stacey M Fernandes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yue Ren
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Yinglu Zhou
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mikaela M McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Heather A Walker
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Monica R McEwan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital, Boston, MA, USA
| | - Eric D Jacobsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ann S LaCasce
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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31
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Robak P, Robak T. Immunotherapy combinations for chronic lymphocytic leukemia: advantages and disadvantages. Expert Opin Biol Ther 2023; 23:21-35. [PMID: 36374125 DOI: 10.1080/14712598.2022.2145881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last few years, BTK inhibitors, PI3K inhibitors, and venetoclax have been approved for clinical use against chronic lymphocytic leukemia (CLL), both as single agents, and in combination. This article summarizes recent achievements in the treatment of patients with CLL, and pays special attention to novel targeted drugs and monoclonal antibodies (Mabs). A literature search was conducted of the PubMed and Google Scholar databases. Rituximab and obinutuzumab have been combined with chemotherapy, and more recently, with BTK inhibitors, PI3K inhibitors, and venetoclax. These agents have demonstrated high activity in treatment naïve (TN) and relapsed or refractory (RR) CLL. Immunochemotherapy regimens are currently considered in TN younger patients with IGHV-mutated disease and should not be given in patients without IGHV mutation. BTK inhibitors are more commonly used as monotherapy in TN and RR patients. PI3K inhibitors can be combined with CD20 Mabs, but their use in CLL is limited due to safety concerns. Venetoclax is typically combined with anti-CD20 Mabs in CLL. Generally, the optimal sequencing of therapies remains to be established, and the selection of upfront therapy needs to be tailored to the individual patient.
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Affiliation(s)
- Pawel Robak
- Department of Experimental Hematology, Medical University of Lodz, Łódź, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Łódź, Poland
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32
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Long-term safety profile of tirabrutinib: final results of a Japanese Phase I study in patients with relapsed or refractory B-cell malignancies. Int J Hematol 2022; 117:553-562. [PMID: 36576659 PMCID: PMC10063512 DOI: 10.1007/s12185-022-03514-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/29/2022]
Abstract
Tirabrutinib is a Bruton's tyrosine kinase inhibitor for treating B-cell malignancies. We report the final results of a Phase I study of tirabrutinib in 17 Japanese patients with B-cell malignancies. Patients were administered tirabrutinib at a dose of 160 mg, 320 mg, or 480 mg once daily, or 300 mg twice daily (N = 3, 3, 4, and 7, respectively). Three patients continued tirabrutinib until study completion (November 30, 2020). Adverse events (AEs) occurred in all 17 patients, with Grade 3-4 AEs in 8 (47.1%), serious AEs in 7 (41.2%), drug-related AEs in 16 (94.1%), and Grade 3-4 drug-related AEs in 6 (35.3%). Drug-related AEs reported in 3 or more patients were rash, vomiting, neutropenia, arthralgia, and malaise. One additional serious AE (benign neoplasm of the lung, unrelated to tirabrutinib) occurred after the previous data cutoff (January 4, 2018). Tirabrutinib administration and response assessment were continued for over 4 years in 4 patients. The overall response rate was 76.5% (13/17 patients). The median (range) time to response and duration of response were 0.9 (0.9-5.9) months and 2.59 (0.08-5.45) years, respectively. These findings demonstrate the long-term safety and efficacy of tirabrutinib in Japanese patients with B-cell malignancies.Clinical trial registration: JapicCTI-142682 ( http://www.clinicaltrials.jp/ ).
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33
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Simon F, Giza A, Robrecht S, Fink AM, Cramer P, von Tresckow J, Fürstenau M, Goede V, Tausch E, Schneider C, Stilgenbauer S, Wendtner CM, Eichhorst B, Fischer K, Hallek M, Al-Sawaf O. Pooled analysis of first-line treatment with targeted agents in patients with chronic lymphocytic leukemia aged 80 years and older. Leuk Lymphoma 2022; 63:3299-3306. [PMID: 36120898 DOI: 10.1080/10428194.2022.2123223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Patients aged 80 years and older make up a fifth of patients with CLL but are underrepresented in clinical trials. We analyzed the outcomes of these patients treated with targeted agents in the front-line setting in six trials of the German CLL Study Group. Targeted agents included venetoclax, ibrutinib, and idelalisib, mainly used in combination with anti-CD20 antibodies. Among 716 patients, 33 matched the selection criteria (5%). Of those, the majority had relevant comorbidity, organ dysfunctions, and/or high-/very high-risk disease. The overall response rate was 73%. The median progression-free survival was 49.2 months compared with those not reached in younger patients. There were 11 documented deaths of which two were deemed related to therapy. Additional results including 40 patients treated with BTK-inhibitors from the GCLLSG registry suggest that treatment with targeted agents is feasible and effective. Dedicated studies are warranted for this particular subgroup of patients.
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Affiliation(s)
- Florian Simon
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Adam Giza
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Julia von Tresckow
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Moritz Fürstenau
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Valentin Goede
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,Department of Oncogeriatrics, Center for Geriatric Medicine, St. Marien-Hospital, Cologne, Germany
| | - Eugen Tausch
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Christof Schneider
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Stephan Stilgenbauer
- Division of CLL, Department of Internal Medicine III, Ulm University, Ulm, Germany
| | - Clemens-Martin Wendtner
- Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine, German CLL Study Group, Munich Clinic Schwabing, Munich, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Düsseldorf, German CLL Study Group, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Cologne, Germany.,The Francis Crick Institute, London, United Kingdom.,UCL Cancer Institute, University College London, London, United Kingdom
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Wierda WG, Kipps TJ, Al-Sawaf O, Chyla B, Biondo JML, Mun Y, Jiang Y, Seymour JF. Utility of measurable residual disease for predicting treatment outcomes with BCR- and BCL2-Targeted therapies in patients with CLL. Leuk Lymphoma 2022; 63:2765-2784. [PMID: 35983732 DOI: 10.1080/10428194.2022.2098291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Inhibitors targeting B-cell receptor (BCR) signaling pathway proteins and B-cell lymphoma-2 (BCL2) in chronic lymphocytic leukemia (CLL) are recommended in the first-line and relapsed/refractory disease settings. Measurable residual disease (MRD) is an important prognostic tool in patients treated with the BCL2-targeted agent, venetoclax. We explored the relationship between MRD status and progression-free (PFS)/overall survival (OS) in patients with CLL, following treatment with novel BCR- and BCL2-targeted agents. Compared with chemoimmunotherapy, higher rates of undetectable (u)MRD were achieved with BCL2-targeted therapies; achieving uMRD status was associated with longer PFS and OS than MRD-positivity. Continuous treatment with BCR-targeted agents did not achieve uMRD status in many patients, and outcomes were not correlated with uMRD status. Future clinical trials of targeted treatment combinations could be designed to demonstrate uMRD as a treatment objective, and allow a response-driven, personalized strategy to optimize treatment and improve OS outcomes.
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Affiliation(s)
| | | | - Othman Al-Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Cologne Aachen Cologne Bonn Düsseldorf, German CLL Study Group, University Hospital, University of Cologne, Cologne, Germany
| | | | | | - Yong Mun
- Genentech, Inc., South San Francisco, CA, USA
| | | | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital & University of Melbourne, Melbourne, VIC, Australia
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Ghia P, Pluta A, Wach M, Lysak D, Šimkovič M, Kriachok I, Illés Á, de la Serna J, Dolan S, Campbell P, Musuraca G, Jacob A, Avery EJ, Lee JH, Usenko G, Wang MH, Yu T, Jurczak W. Acalabrutinib Versus Investigator’s Choice in Relapsed/Refractory Chronic Lymphocytic Leukemia: Final ASCEND Trial Results. Hemasphere 2022; 6:e801. [PMID: 36398134 PMCID: PMC9666115 DOI: 10.1097/hs9.0000000000000801] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/05/2022] [Indexed: 11/16/2022] Open
Abstract
Acalabrutinib is a Bruton tyrosine kinase inhibitor approved for patients with chronic lymphocytic leukemia (CLL). ASCEND is the pivotal phase 3 study of acalabrutinib versus investigator’s choice of idelalisib plus rituximab (IdR) or bendamustine plus rituximab (BR) in patients with relapsed/refractory (R/R) CLL. In the primary ASCEND analysis (median 16.1-month follow-up), acalabrutinib showed superior efficacy with an acceptable tolerability profile versus IdR/BR; here, we report final ~4 year follow-up results. Patients with R/R CLL received oral acalabrutinib 100 mg twice daily until progression or unacceptable toxicity, or investigator’s choice of IdR or BR. A total of 310 patients (acalabrutinib, n = 155; IdR, n = 119; BR, n = 36) were enrolled. At median follow-up of 46.5 months (acalabrutinib) and 45.3 months (IdR/BR), acalabrutinib significantly prolonged investigator-assessed progression-free survival (PFS) versus IdR/BR (median, not reached [NR] vs 16.8 months; P < 0.001); 42-month PFS rates were 62% (acalabrutinib) versus 19% (IdR/BR). Median overall survival (OS) was NR (both arms); 42-month OS rates were 78% (acalabrutinib) versus 65% (IdR/BR). Adverse events led to drug discontinuation in 23%, 67%, and 17% of patients in the acalabrutinib, IdR, and BR arms, respectively. Events of clinical interest (acalabrutinib vs IdR/BR) included all-grade atrial fibrillation/flutter (8% vs 3%), all-grade hypertension (8% vs 5%), all-grade major hemorrhage (3% vs 3%), grade ≥3 infections (29% vs 29%), and second primary malignancies excluding nonmelanoma skin cancer (7% vs 2%). At ~4 years follow-up, acalabrutinib maintained favorable efficacy versus standard-of-care regimens and a consistent tolerability profile in patients with R/R CLL.
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Wan Q, Li Q, Lai X, Xu T, Hu J, Peng H. Data mining and safety analysis of BTK inhibitors: A pharmacovigilance investigation based on the FAERS database. Front Pharmacol 2022; 13:995522. [PMID: 36438789 PMCID: PMC9691840 DOI: 10.3389/fphar.2022.995522] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/25/2022] [Indexed: 08/31/2023] Open
Abstract
Objective: The introduction of Bruton's tyrosine kinase (BTK) inhibitors was a milestone in the treatment of B-cell malignancies in recent years owing to its desired efficacy against chronic lymphocytic leukaemia and small cell lymphocytic lymphoma. However, safety issues have hindered its application in clinical practice. The current study aimed to explore the safety warning signals of BTK inhibitors in a real-world setting using the FDA Adverse Event Reporting System (FAERS) to provide reference for clinical rational drug use. Methods: Owing to the short marketing time of other drugs (zanbrutinib and orelabrutinib), we only analysed ibrutinib and acalabrutinib in this study. All data were obtained from the FAERS database from January 2004 to December 2021. Disproportionality analysis and Bayesian analysis were utilised to detect and assess the adverse event (AE) signals of BTK inhibitors. Results: In total, 43,429 reports of ibrutinib were extracted and 1527 AEs were identified, whereas 1742 reports of acalabrutinib were extracted and 220 AEs were identified by disproportionality analysis and Bayesian analysis. Among reports, males were more prone to develop AEs (58.2% for males vs. 35.6% for females treated with ibrutinib, and 55.9% vs. 31.9%, respectively, for acalabrutinib), and more than 30% of patients that suffered from AEs were over 65 years of age. Subsequently, we investigated the top 20 preferred terms (PTs) associated with the signal strength of ibrutinib and acalabrutinib, and our results identified 25 (13 vs. 12, respectively) novel risk signals. Among the top 20 PTs related to death reports, the terms infectious, pneumonia, pleural effusion, fall, asthenia, diarrhoea, and fatigue were all ranked high for these two BTK inhibitors. Further, cardiac disorders were also an important cause of death with ibrutinib. Conclusion: Patients treated with ibrutinib were more prone to develop AEs than those treated with acalabrutinib. Importantly, infection-related adverse reactions, such as pneumonia and pleural effusion, were the most common risk signals related to high mortality associated with both BTK inhibitors, especially in elderly patients. Moreover, cardiovascular-related adverse reactions, such as atrial fibrillation and cardiac failure, were fatal AEs associated with ibrutinib. Our results provide a rationale for physicians to choose suitable BTK inhibitors for different patients and provide appropriate monitoring to achieve safer therapy and longer survival.
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Affiliation(s)
- Qing Wan
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qiang Li
- Department of Chemotherapy, Jiangxi Cancer Hospital, Nanchang, China
| | - Xin Lai
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Tiantian Xu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jinfang Hu
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hongwei Peng
- Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Gu D, Li J, Miao Y. Evaluating orelabrutinib as a novel treatment option for relapsed/refractory chronic lymphocytic leukemia in China. Expert Opin Pharmacother 2022; 23:1979-1986. [DOI: 10.1080/14656566.2022.2144218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Danling Gu
- Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
- Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - Jianyong Li
- Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
- Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
| | - Yi Miao
- Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
- Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing 210029, China
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Alu A, Lei H, Han X, Wei Y, Wei X. BTK inhibitors in the treatment of hematological malignancies and inflammatory diseases: mechanisms and clinical studies. J Hematol Oncol 2022; 15:138. [PMID: 36183125 PMCID: PMC9526392 DOI: 10.1186/s13045-022-01353-w] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Bruton's tyrosine kinase (BTK) is an essential component of multiple signaling pathways that regulate B cell and myeloid cell proliferation, survival, and functions, making it a promising therapeutic target for various B cell malignancies and inflammatory diseases. Five small molecule inhibitors have shown remarkable efficacy and have been approved to treat different types of hematological cancers, including ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and orelabrutinib. The first-in-class agent, ibrutinib, has created a new era of chemotherapy-free treatment of B cell malignancies. Ibrutinib is so popular and became the fourth top-selling cancer drug worldwide in 2021. To reduce the off-target effects and overcome the acquired resistance of ibrutinib, significant efforts have been made in developing highly selective second- and third-generation BTK inhibitors and various combination approaches. Over the past few years, BTK inhibitors have also been repurposed for the treatment of inflammatory diseases. Promising data have been obtained from preclinical and early-phase clinical studies. In this review, we summarized current progress in applying BTK inhibitors in the treatment of hematological malignancies and inflammatory disorders, highlighting available results from clinical studies.
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Affiliation(s)
- Aqu Alu
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hong Lei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Bruton’s Tyrosine Kinase Inhibitor Zanubrutinib Effectively Modulates Cancer Resistance by Inhibiting Anthracycline Metabolism and Efflux. Pharmaceutics 2022; 14:pharmaceutics14101994. [PMID: 36297430 PMCID: PMC9611657 DOI: 10.3390/pharmaceutics14101994] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/29/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Zanubrutinib (ZAN) is a Bruton’s tyrosine kinase inhibitor recently approved for the treatment of some non-Hodgkin lymphomas. In clinical trials, ZAN is often combined with standard anthracycline (ANT) chemotherapy. Although ANTs are generally effective, drug resistance is a crucial obstacle that leads to treatment discontinuation. This study showed that ZAN counteracts ANT resistance by targeting aldo-keto reductase 1C3 (AKR1C3) and ATP-binding cassette (ABC) transporters. AKR1C3 catalyses the transformation of ANTs to less potent hydroxy-metabolites, whereas transporters decrease the ANT-effective concentrations by pumping them out of the cancer cells. In our experiments, ZAN inhibited the AKR1C3-mediated inactivation of daunorubicin (DAUN) at both the recombinant and cellular levels. In the drug combination experiments, ZAN synergistically sensitised AKR1C3-expressing HCT116 and A549 cells to DAUN treatment. Gene induction studies further confirmed that ZAN did not increase the intracellular level of AKR1C3 mRNA; thus, the drug combination effect is not abolished by enzyme induction. Finally, in accumulation assays, ZAN was found to interfere with the DAUN efflux mediated by the ABCB1, ABCG2, and ABCC1 transporters, which might further contribute to the reversal of ANT resistance. In summary, our data provide the rationale for ZAN inclusion in ANT-based therapy and suggest its potential for the treatment of tumours expressing AKR1C3 and/or the above-mentioned ABC transporters.
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Dong R, Yan Y, Zeng X, Lin N, Tan B. Ibrutinib-Associated Cardiotoxicity: From the Pharmaceutical to the Clinical. Drug Des Devel Ther 2022; 16:3225-3239. [PMID: 36164415 PMCID: PMC9508996 DOI: 10.2147/dddt.s377697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 12/06/2022] Open
Abstract
Ibrutinib is the first-in-class Bruton tyrosine kinase (BTK) inhibitor that has revolutionized the treatment of B cell malignancies. Unfortunately, increased incidences of cardiotoxicity have limited its use. Despite over a decade of research, the biological mechanisms underlying ibrutinib cardiotoxicity remain unclear. In this review, we discuss the pharmacological properties of ibrutinib, the incidence and mechanisms of ibrutinib-induced cardiotoxicity, and practical management to prevent and treat this condition. We also synopsize and discuss the cardiovascular adverse effects related to other more selective BTK inhibitors, which may guide the selection of appropriate BTK inhibitors.
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Affiliation(s)
- Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Youyou Yan
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Nengming Lin
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
- Nengming Lin, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 903, No. 7 Building, Hangzhou, People’s Republic of China, Tel/Fax +86-571-56005600, Email
| | - Biqin Tan
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Correspondence: Biqin Tan, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 207, No. 5 Building, Hangzhou, People’s Republic of China, Tel +86-571-56007824, Fax +86-571-56005600, Email
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Lovell AR, Jammal N, Bose P. Selecting the optimal BTK inhibitor therapy in CLL: rationale and practical considerations. Ther Adv Hematol 2022; 13:20406207221116577. [PMID: 35966045 PMCID: PMC9373150 DOI: 10.1177/20406207221116577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Bruton’s tyrosine kinase (BTK) inhibitors have dramatically changed the treatment
of newly diagnosed and relapsed/refractory chronic lymphocytic leukemia (CLL).
Ibrutinib, acalabrutinib, and zanubrutinib are Food and Drug Administration
(FDA)-approved BTK inhibitors that have all demonstrated progression-free
survival (PFS) benefit compared with chemoimmunotherapy. The efficacy of these
agents compared to one another is under study; however, current data suggest
they provide similar efficacy. Selectivity for BTK confers different adverse
effect profiles, and longer follow-up and real-world use have characterized side
effects over time. The choice of BTK inhibitor is largely patient-specific, and
this review aims to highlight the differences among the agents and guide the
choice of BTK inhibitor in clinical practice.
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Affiliation(s)
- Alexandra R Lovell
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nadya Jammal
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030, USA
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Hatashima A, Karami M, Shadman M. Approved and emerging Bruton's tyrosine kinase inhibitors for the treatment of chronic lymphocytic leukemia. Expert Opin Pharmacother 2022; 23:1545-1557. [PMID: 35973973 DOI: 10.1080/14656566.2022.2113384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The Bruton's tyrosine kinase (BTK) pathway has proven to be an effective and transformative therapeutic target in the treatment of chronic lymphocytic leukemia (CLL), fueling the growth of BTK inhibitors (BTKis) and landmark approval of first-generation BTKi, ibrutinib. However, ibrutinib's side effect profile left an unmet need for BTKis with improved tolerability thus spurring the subsequent development of second-generation acalabrutinib and zanubrutinib. The treatment landscape continues to evolve with studies using BTKi combination therapies, notably with venetoclax, with and without an anti-CD20 monoclonal antibody as well as third generation BTKis aimed to overcome BTKi resistance. AREAS COVERED This article details the current literature highlighting the efficacy, toxicities, and potential therapeutic combinations of approved and preclinical BTKis. EXPERT OPINION BTKis have signaled the start of a new treatment paradigm in CLL and improved clinical outcomes especially for patients with high-risk disease. However, drug resistance, low CR rates, and indefinite treatment necessitate the development of novel BTKis and fixed duration combination therapy. The results from recently completed and ongoing clinical trials are eagerly awaited with the potential promise of reduced treatment durations and financial burden while achieving durable remissions.
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Affiliation(s)
| | | | - Mazyar Shadman
- Fred Hutch Cancer Center, Seattle WA.,University of Washington, Seattle WA
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Omi A, Nomura F, Tsujioka S, Fujino A, Akizuki R. Efficacy and safety of ibrutinib in relapsed/refractory CLL and SLL in Japan: a post-marketing surveillance. J Clin Exp Hematop 2022; 62:136-146. [PMID: 35831100 PMCID: PMC9635026 DOI: 10.3960/jslrt.22002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ibrutinib is approved in Japan for the treatment of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) based on the results of global and domestic clinical studies. Following approval, we conducted an all-case post-marketing surveillance in Japanese patients with relapsed/refractory CLL/SLL newly initiated on ibrutinib treatment between May 2016−September 2017. Of the 323 patients enrolled, the safety and efficacy analysis sets comprised 289 and 205 patients, respectively. The overall response rate with ibrutinib treatment was 64.4%, and the estimated 52-week progression-free survival (PFS) and overall survival (OS) rates were 71.7 and 79.1%, respectively. No significant difference in the PFS rate was observed among patients with and without del(17p) (P = 0.160); however, PFS was significantly longer in patients who received 1 prior line of therapy versus >1 prior lines of therapy (P = 0.007). Adverse events occurred in 74.0% of patients, and typically occurred early (≤12 weeks) after ibrutinib initiation, followed by a decline in incidence thereafter. The overall rates of infection, bleeding, and arrhythmia were 22.5, 12.8, and 4.8%, respectively. Grade ≥3 bleeding events and atrial fibrillation occurred in 2.4% of patients each. The efficacy and safety profile of ibrutinib treatment in routine clinical practice was consistent with clinical trials and previously reported domestic data. UMIN-CTR Clinical Trials Register ID: UMIN000021963.
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Affiliation(s)
- Ai Omi
- Medical Affairs Division, Janssen Pharmaceutical K.K., Tokyo, Japan
| | - Fumi Nomura
- Safety and Surveillance Division, Janssen Pharmaceutical K.K., Tokyo, Japan
| | - Shigeharu Tsujioka
- Safety and Surveillance Division, Janssen Pharmaceutical K.K., Tokyo, Japan
| | - Akiko Fujino
- Safety and Surveillance Division, Janssen Pharmaceutical K.K., Tokyo, Japan
| | - Reiko Akizuki
- Medical Affairs Division, Janssen Pharmaceutical K.K., Tokyo, Japan
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Larsson K, Söderling J, Höglund M, Glimelius I, Mattsson M. Cardiovascular disease in patients with chronic lymphocytic leukemia: A Swedish nationwide register study with matched comparators. Am J Hematol 2022; 97:E255-E257. [PMID: 35384027 DOI: 10.1002/ajh.26558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/28/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Karin Larsson
- Department of Blood and Tumor Diseases Uppsala University Hospital Uppsala Sweden
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Jonas Söderling
- Division of Clinical Epidemiology, Department of Medicine Karolinska Institute Stockholm Sweden
| | - Martin Höglund
- Department of Blood and Tumor Diseases Uppsala University Hospital Uppsala Sweden
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Ingrid Glimelius
- Department of Blood and Tumor Diseases Uppsala University Hospital Uppsala Sweden
- Division of Clinical Epidemiology, Department of Medicine Karolinska Institute Stockholm Sweden
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
| | - Mattias Mattsson
- Department of Blood and Tumor Diseases Uppsala University Hospital Uppsala Sweden
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
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Frustaci AM, Deodato M, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. SOHO State of the Art Updates and Next Questions: What is Fitness in the Era of Targeted Agents? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:356-361. [PMID: 34969641 DOI: 10.1016/j.clml.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 06/14/2023]
Abstract
The importance of coexisting conditions in chronic lymphocytic leukemia (CLL) outcome has been increasingly recognized over the past years. The role of comorbidities to predict patients' vulnerability toward immunochemotherapy has been well establish, especially since some of the tools commonly used to evaluate patients' fitness were employed to determine treatment eligibility in randomized trials. Nevertheless, is it still unclear how much fitness weights on treatment outcome with targeted agents and which assessment should be preferred. There are key differences in the toxicity profile between novel agents that are getting much more evident in retrospective, real-life experiences, rather than clinical trials. Therefore, an individual patient's comorbid medical conditions may be a deciding factor in therapy selection. Here, we analyze main evidence in literature on the predicting value of comorbidity assessment on outcome and management of CLL patients receiving novel agents.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy.
| | - Marina Deodato
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Giulia Zamprogna
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Roberto Cairoli
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Marco Montillo
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
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Keegan A, Dennington PM, Dhondy N, Mulligan SP. Immunoglobulin replacement therapy in chronic lymphocytic leukaemia patients with hypogammaglobulinaemia and infection. Eur J Haematol 2022; 108:460-468. [PMID: 35152500 DOI: 10.1111/ejh.13754] [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: 12/27/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyse total national utilisation of immunoglobulin (Ig) replacement therapy (IgRT) for Chronic Lymphocytic Leukaemia patients with acquired hypogammaglobulinaemia and severe and/or recurrent bacterial infections. METHODS In 2007, the National Blood Authority first published Criteria for the clinical use of intravenous immunoglobulin in Australia. The Australian Red Cross Lifeblood assessed, approved, and recorded all supply with patient demographics, distribution data, intravenous Ig (IVIg) volumes and treatment episodes. IVIg was the sole product used in Australia from 2008-2013 inclusive. RESULTS From 2008 to 2013 across Australia, 2734 individual CLL patients received 48,870 treatment episodes using a total 1,324,926 g of IVIg therapy. Six IVIg products were available, with domestically manufactured Intragam® P accounting for 89.7% of supply. The average age for first dose was 74 years. Males received 60.6% of the total treatment episodes representing 20% more than females. The average pre-treatment IgG level was 4.03 ± 2.03 g/L (range 0.30-10.50 g/L). A sustained average annual increased IVIg utilisation of 5.5% was observed. There was significant regional variation consistent with differences in prescriber preferences across states and territories. CONCLUSION This study provides a globally unique insight into IgRT supply and demand in CLL patients by analysis of total national use in Australia over a 6-year period.
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Affiliation(s)
- Anastazia Keegan
- Australian Red Cross Lifeblood, Perth, Western Australia, Australia
| | - Peta M Dennington
- Australian Red Cross Lifeblood, Alexandria, Sydney, New South Wales, Australia
| | - Nina Dhondy
- Australian Red Cross Lifeblood, Alexandria, Sydney, New South Wales, Australia.,Department of Haematology, Laverty Pathology, Sydney, New South Wales, Australia
| | - Stephen P Mulligan
- Department of Haematology, Laverty Pathology, Sydney, New South Wales, Australia.,Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Rivera D, Ferrajoli A. Managing the Risk of Infection in Chronic Lymphocytic Leukemia in the Era of New Therapies. Curr Oncol Rep 2022; 24:1003-1014. [PMID: 35366167 PMCID: PMC8976213 DOI: 10.1007/s11912-022-01261-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/29/2022]
Abstract
Purpose of Review Patients diagnosed with CLL have an increased susceptibility to infections. Over the years, there has been a shift of the treatment arsenal to an increasing use of chemotherapy-free regimens, particularly small molecule inhibitors. These therapies have proven to be effective and have a favorable toxicity profile. Infections continue to represent a significant complication in the era of novel therapies. Recent Findings Recent studies continue to bring new insights into the effects of modern therapies on the immune system. Evidence supporting infection prevention strategies is scarce. We will review the available recommendations to prevent infections in patients with CLL treated with novel therapies. Summary New CLL therapies are broadly adopted in routine practice, requiring optimization of their side effects. Timely prevention, recognition, and treatment of infections should remain an important aspect of the standard management of a patient with CLL.
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Affiliation(s)
- Daniel Rivera
- Department of Leukemia, The University of Texas-MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas-MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA.
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New Treatment Options for Newly-Diagnosed and Relapsed Chronic Lymphocytic Leukemia. Curr Treat Options Oncol 2022; 23:775-795. [PMID: 35357653 DOI: 10.1007/s11864-022-00974-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2022] [Indexed: 11/03/2022]
Abstract
OPINION STATEMENT The better understanding of the biology of chronic lymphocytic leukemia (CLL) gained over the past decade has led to the development and introduction of several targeted drugs, with an demonstrable improvement in the prognosis for this currently incurable condition. Currently, Bruton's tyrosine kinase (BTK) inhibitors, phosphoinositide 3-kinase (PI3K) inhibitors, venetoclax, and CD20 monoclonal antibodies are the key elements in the treatment of both previously untreated and relapsed/refractory CLL patients. Ibrutinib was the first BTK inhibitor approved for clinical use, and showed excellent efficacy and an acceptable safety profile. Following this, the better-tolerated second-generation irreversible BTK inhibitors acalabrutinib and zanubrutinib have been introduced for the treatment of lymphoid malignancies, and acalabrutinib was approved for CLL. When used as single drugs, BTK inhibitors are given continuously until unacceptable toxicity or disease progression; however, when combined with venetoclax and/or CD20 antibodies, they induce deeper response and can be given for a limited time. Recently, promising new reversible BTK inhibitors pirtobrutinib and nemtabrutinib were discovered, and these seem to be more active and better tolerated than their irreversible predecessors. However, they are in an early phase of development and are not currently approved for CLL. The phosphatidylinositol 3-kinase (PI3K) inhibitors idelalisib and duvelisib are highly effective in patients with relapsed CLL, including high-risk disease. The major limitations for their use are adverse events, mostly of autoimmune origin (hepatitis, enteritis/colitis, and pneumonitis). Otherwise, cellular therapies like allogeneic hematopoietic stem cell transplantation and chimeric antigen receptor (CAR) T cells and bispecific monoclonal antibodies offer promise for patients who have failed BTK inhibitors and venetoclax treatment. In the coming years, it is likely that novel targeted therapies will replace immunochemotherapy regimens in most patients.
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Ye Q, Lin Y, Li R, Wang H, Dong C. Recent advances of nanodrug delivery system in the treatment of hematologic malignancies. Semin Cancer Biol 2022; 86:607-623. [PMID: 35339668 DOI: 10.1016/j.semcancer.2022.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/19/2022] [Accepted: 03/19/2022] [Indexed: 12/17/2022]
Abstract
Although the survival rate of hematological malignancies (HM) has increased in recent years, the unnecessary adverse effect to the body is usually generated by the traditional chemotherapy for HM due to the lack of specificity to tumor tissue. Nanodrug delivery systems have exhibited unique advantages in targetability, stability and reducing toxicity, attracting wide concern, which is expected to be the prevalent alternative for the treatment of HM. In this review, we systemically introduced the current therapeutic strategies and the categories of HM. Subsequently, five key factors including circulation, targeting, penetration, internalization and release involving in tailoring nanoparticles were demonstrated, followed by the introduction of the development of nanodrug delivery-traditional synthetic nanomaterilas, biomimetic cell membrane coating nanomaterials, cell-based nanomaterials as well as immunotherapy combined with nanodrug. Afterwards, the recent advances of nanodrug delivery system for the treatment of HM were introduced. Moreover, the challenge and prospect of nanodrug delivery system in treating HM were discussed. The promising drug delivery system will provide new therapeutic avenues for the treatment of HM.
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Affiliation(s)
- Qianling Ye
- Breast Cancer Center, East Hospital Affiliated to Tongji University, Tongji University School of Medicine, Shanghai Key Laboratory of Chemical Assessment and Sustainability, School of Chemical Science and Engineering, Tongji University, Shanghai, People's Republic of China
| | - Yun Lin
- Breast Cancer Center, East Hospital Affiliated to Tongji University, Tongji University School of Medicine, Shanghai Key Laboratory of Chemical Assessment and Sustainability, School of Chemical Science and Engineering, Tongji University, Shanghai, People's Republic of China
| | - Ruihao Li
- Breast Cancer Center, East Hospital Affiliated to Tongji University, Tongji University School of Medicine, Shanghai Key Laboratory of Chemical Assessment and Sustainability, School of Chemical Science and Engineering, Tongji University, Shanghai, People's Republic of China
| | - Huaiji Wang
- Department of Nephrology, Shanghai Fourth People's Hospital, School of Medicine, Tongji University, Shanghai, People's Republic of China.
| | - Chunyan Dong
- Breast Cancer Center, East Hospital Affiliated to Tongji University, Tongji University School of Medicine, Shanghai Key Laboratory of Chemical Assessment and Sustainability, School of Chemical Science and Engineering, Tongji University, Shanghai, People's Republic of China.
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50
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Burley TA, Hesketh A, Bucca G, Kennedy E, Ladikou EE, Towler BP, Mitchell S, Smith CP, Fegan C, Johnston R, Pepper A, Pepper C. Elucidation of Focal Adhesion Kinase as a Modulator of Migration and Invasion and as a Potential Therapeutic Target in Chronic Lymphocytic Leukemia. Cancers (Basel) 2022; 14:cancers14071600. [PMID: 35406371 PMCID: PMC8996841 DOI: 10.3390/cancers14071600] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023] Open
Abstract
The retention and re-migration of Chronic Lymphocytic Leukemia cells into cytoprotective and proliferative lymphoid niches is thought to contribute to the development of resistance, leading to subsequent disease relapse. The aim of this study was to elucidate the molecular processes that govern CLL cell migration to elicit a more complete inhibition of tumor cell migration. We compared the phenotypic and transcriptional changes induced in CLL cells using two distinct models designed to recapitulate the peripheral circulation, CLL cell migration across an endothelial barrier, and the lymph node interaction between CLL cells and activated T cells. Initially, CLL cells were co-cultured with CD40L-expressing fibroblasts and exhibited an activated B-cell phenotype, and their transcriptional signatures demonstrated the upregulation of pro-survival and anti-apoptotic genes and overrepresentation of the NF-κB signaling pathway. Using our dynamic circulating model, we were able to study the transcriptomics and miRNomics associated with CLL migration. More than 3000 genes were altered when CLL cells underwent transendothelial migration, with an overrepresentation of adhesion and cell migration gene sets. From this analysis, an upregulation of the FAK signaling pathway was observed. Importantly, PTK2 (FAK) gene expression was significantly upregulated in migrating CLL cells (PTK2 Fold-change = 4.9). Here we demonstrate that TLR9 agonism increased levels of p-FAK (p ≤ 0.05), which could be prevented by pharmacological inhibition of FAK with defactinib (p ≤ 0.01). Furthermore, a reduction in CLL cell migration and invasion was observed when FAK was inhibited (p ≤ 0.0001), supporting a role for FAK in both CLL migration and tissue invasion. When taken together, our data highlights the potential for combining FAK inhibition with current targeted therapies as a more effective treatment regime for CLL.
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Affiliation(s)
- Thomas A. Burley
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
| | - Andrew Hesketh
- School of Applied Sciences, University of Brighton, Brighton BN2 4GJ, UK; (A.H.); (G.B.); (C.P.S.)
| | - Giselda Bucca
- School of Applied Sciences, University of Brighton, Brighton BN2 4GJ, UK; (A.H.); (G.B.); (C.P.S.)
| | - Emma Kennedy
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
| | - Eleni E. Ladikou
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
- Department of Haematology, Brighton and Sussex University Hospital Trust, Brighton BN2 5BE, UK;
| | - Benjamin P. Towler
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
| | - Simon Mitchell
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
| | - Colin P. Smith
- School of Applied Sciences, University of Brighton, Brighton BN2 4GJ, UK; (A.H.); (G.B.); (C.P.S.)
- Department of Nutritional Sciences, Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford GU2 7YH, UK
| | - Christopher Fegan
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK;
| | - Rosalynd Johnston
- Department of Haematology, Brighton and Sussex University Hospital Trust, Brighton BN2 5BE, UK;
| | - Andrea Pepper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
- Correspondence: ; Tel.: +44-01273-678644
| | - Chris Pepper
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Falmer, Brighton BN1 9PX, UK; (T.A.B.); (E.K.); (E.E.L.); (B.P.T.); (S.M.); (C.P.)
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