Optimal sequencing of ibrutinib, idelalisib, and venetoclax in chronic lymphocytic leukemia: results from a multicenter study of 683 patients

Background

Ibrutinib, idelalisib, and venetoclax are approved for treating CLL patients in the United States. However, there is no guidance as to their optimal sequence.

Patients and methods

We conducted a multicenter, retrospective analysis of CLL patients treated with kinase inhibitors (KIs) or venetoclax. We examined demographics, discontinuation reasons, overall response rates (ORR), survival, and post-KI salvage strategies. Primary endpoint was progression-free survival (PFS).

Results

A total of 683 patients were identified. Baseline characteristics were similar in the ibrutinib and idelalisib groups. ORR to ibrutinib and idelalisib as first KI was 69% and 81%, respectively. With a median follow-up of 17 months (range 1-60), median PFS and OS for the entire cohort were 35 months and not reached. Patients treated with ibrutinib (versus idelalisib) as first KI had a significantly better PFS in all settings; front-line [hazard ratios (HR) 2.8, CI 1.3-6.3, P = 0.01], relapsed-refractory (HR 2.8, CI 1.9-4.1, P < 0.001), del17p (HR 2.0, CI 1.2-3.4, P = 0.008), and complex karyotype (HR 2.5, CI 1.2-5.2, P = 0.02). At the time of initial KI failure, use of an alternate KI or venetoclax had a superior PFS when compared with chemoimmunotherapy. Furthermore, patients who discontinued ibrutinib due to progression or toxicity had marginally improved outcomes if they received venetoclax (ORR 79%) versus idelalisib (ORR 46%) (PFS HR .6, CI.3-1.0, P = 0.06).

Conclusions

In the largest real-world experience of novel agents in CLL, ibrutinib appears superior to idelalisib as first KI. Furthermore, in the setting of KI failure, alternate KI or venetoclax therapy appear superior to chemoimmunotherapy combinations. The use of venetoclax upon ibrutinib failure might be superior to idelalisib. These data support the need for trials testing sequencing strategies to optimize treatment algorithms.

Effect of histological processing and methacrylate sectioning on the area of gill tissue in teleost

Deformation of biological tissues may occur during histological processing and results in loss of accuracy when quantitative information about cells, tissues and organs is necessary. In this study, the gill tissue from armored catfish (Pterygoplichthys anisitsi) was quantified in each step of processing using the stereological principles. During processing for glycol methacrylate embedding, gill tissue from shrinks significantly but regains its original dimensions after sectioning.

Persistent cerebrovascular changes in postpartum preeclamptic women: a Doppler evaluation

OBJECTIVE

Our goal was to evaluate the cerebral vasculature in postpartum normotensive and preeclamptic women.

STUDY DESIGN

Nineteen previously preeclamptic women and 19 matched normotensive controls were studied at 6 weeks, and 8 preeclamptic women and 28 normotensive controls were studied at 12 weeks post partum. Systolic, diastolic, and mean velocities, as well as resistance and pulsatility indexes, of the middle cerebral, ophthalmic, and central retinal arteries were recorded. Data are presented as median and range. Statistical significance was set at p < 0.05.

RESULTS

There were no differences in maternal age, parity, heart rate, mean arterial pressure, and proteinuria between the two groups at 6 and 12 weeks post partum. At 6 weeks post partum the preeclamptic group had higher ophthalmic artery diastolic velocity (9.0 cm/sec, 3.1 to 22.3, vs 5.4 cm/sec, 3.0 to 20.1; p = 0.008), ophthalmic artery mean velocity (6.0 cm/sec, 8.8 to 34.8, vs 12.5 cm/sec, 6.8 to 35.4; p = 0.03), and central retinal artery systolic velocity (10.0 cm/sec, 7.6 to 28.0, vs 8.4 cm/sec, 5.2 to 18.3; p = 0.02). The ophthalmic artery resistance index (0.72, 0.43 to 0.88, vs 0.79, 0.66 to 0.90; p = 0.03) and ophthalmic artery pulsatility index (1.56, 0.94 to 2.82, vs 2.03, vs 1.13 to 3.10; p = 0.04) were lower in the preeclamptic group. At 12 weeks post partum the preeclamptic group had elevated ophthalmic artery mean velocity (14.5 cm/sec, 7.9 to 20.2, vs 10.9 cm/sec, 5.5 to 15.4 p = 0.01), central retinal artery systolic velocity (11.1 cm/sec, 6.8 to 15.9, vs 8.5, 5.1 to 15.3; p = 0.02), and central retinal artery diastolic velocity (3.9 cm/sec, 1.2 to 5.2, vs 3.0, 1.4 to 5.8; p < 0.05).

CONCLUSION

In the postpartum period preeclamptic women show persistently elevated central retinal artery systolic velocity, which suggests distal vasoconstriction.

Elevated concentrations of plasma omega-3 polyunsaturated fatty acids among Alaskan Eskimos

Eskimos living in rural southwestern Alaska depend on fish and marine mammals as major sources of subsistence food. Fatty acid concentrations in 80 Yupik Eskimos living in either a coastal or river village of southwestern Alaska were compared with those of non-Native control subjects. Concentrations of total plasma omega-3 fatty acids, eicosapentaenoic acid (20:5 omega-3), and docosahexaenoic acid (22:6 omega-3) were 4.3, 13, and 6.8 times higher, respectively, in Native participants than in non-Native control subjects. Concentrations of these fatty acids were higher in coastal-village than in river-village participants; concentrations paralleled consumption of marine mammal oil and marine fish. The ratios of eicosapentaenoic to arachidonic acid for adult coastal- and river-village participants were 1.16 and 0.70, respectively, 14 and 9 times those of non-Native adults, respectively. There was no increase in the mean bleeding times of Native participants of either village.