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Parrondo RD, Dutta N, LaPlant BR, Elliott J, Fernandez A, Zimmerman A, Cicco G, Han B, Heslop K, Chapin D, Sher T, Roy V, Rasheed A, Das S, Chanan-Khan AA, Paulus A, Ailawadhi S. A phase II study of ibrutinib in combination with ixazomib in patients with Waldenström macroglobulinaemia. Br J Haematol 2024; 204:1825-1829. [PMID: 38286472 DOI: 10.1111/bjh.19320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/31/2024]
Abstract
This phase II study evaluated time-limited (24 cycles) treatment with ibrutinib and ixazomib in newly diagnosed (NDWM; n = 9) and relapsed/refractory (RRWM; n = 12) Waldenström macroglobulinaemia (WM). The overall response rate (ORR) was 76.2% (n = 16) in 21 evaluable patients with no patient achieving a complete response (CR). The median duration of treatment was 15.6 months, and after a median follow-up time of 25.7 months, the median progression-free survival (PFS) was 22.9 months. While the primary end-point was not met (CR rate at any time) and 28.5% discontinued treatment due to toxicity, ibrutinib plus ixazomib led to a clinically meaningful ORR and PFS. Combined Bruton's tyrosine kinase (BTK) and proteasome inhibition merits further evaluation in WM.
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Affiliation(s)
| | - Navnita Dutta
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Betsy R LaPlant
- Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie Elliott
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | | | | | - Gina Cicco
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bing Han
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Keisha Heslop
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Dustin Chapin
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Taimur Sher
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Vivek Roy
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Ahsan Rasheed
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Saurav Das
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
| | - Asher A Chanan-Khan
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Aneel Paulus
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
| | - Sikander Ailawadhi
- Mayo Clinic Cancer Center, Jacksonville, Florida, USA
- Department of Cancer Biology, Mayo Clinic, Jacksonville, Florida, USA
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2
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Ailawadhi S, Parrondo RD, Dutta N, Han B, Ciccio G, Cherukuri Y, Alegria VR, LaPlant BR, Roy V, Sher T, Edwards B, Lanier S, Manna A, Heslop K, Caulfield T, Maldosevic E, Storz P, Manochakian R, Asmann Y, Chanan-Khan AA, Paulus A. AT-101 Enhances the Antitumor Activity of Lenalidomide in Patients with Multiple Myeloma. Cancers (Basel) 2023; 15:477. [PMID: 36672426 PMCID: PMC9857228 DOI: 10.3390/cancers15020477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/03/2022] [Accepted: 12/09/2022] [Indexed: 01/15/2023] Open
Abstract
Bcl-2 and Mcl-1 proteins play a role in multiple myeloma (MM) cell survival, for which targeted inhibitors are being developed. AT-101 is an oral drug, which disrupts Bcl-2 and Mcl-1 function, impedes mitochondrial bioenergetic processes and induces apoptosis in MM cells. When combined with lenalidomide and dexamethasone (Rd), AT-101 significantly reduced tumor burden in an in vivo xenograft model of MM. These data provided rationale for a phase I/II study to establish the effective dose of AT-101 in combination with Rd (ARd regimen) in relapsed/refractory MM. A total of 10 patients were enrolled, most with high-risk cytogenetics (80%) and prior stem cell transplant (70%). Three patients were lenalidomide-refractory, 2 were bortezomib-refractory and 3 were daratumumab-refractory. The ARd combination was well tolerated with most common grade 3/4 adverse events being cytopenia's. The overall response rate was 40% and clinical benefit rate was 90%. The median progression free survival was 14.9 months (95% CI 7.1-NE). Patients responsive to ARd showed a decrease in Bcl-2:Bim or Mcl-1:Noxa protein complexes, increased CD8+ T and NK cells and depletion of T and B-regulatory cells. The ARd regimen demonstrated an acceptable safety profile and promising efficacy in patients with relapsed/refractory MM prompting further investigation in additional patients.
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Affiliation(s)
- Sikander Ailawadhi
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Ricardo D. Parrondo
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Navnita Dutta
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Bing Han
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Gina Ciccio
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Yesesri Cherukuri
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Victoria R. Alegria
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Betsy R. LaPlant
- Department of Biostatistics, Mayo Clinic Rochester, Rochester, MN 55902, USA
| | - Vivek Roy
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Taimur Sher
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Brett Edwards
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Stephanie Lanier
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Alak Manna
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Keisha Heslop
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Thomas Caulfield
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Emir Maldosevic
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Peter Storz
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Rami Manochakian
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Yan Asmann
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Asher A. Chanan-Khan
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
| | - Aneel Paulus
- Deparment of Hematology-Oncology, Mayo Clinic Florida, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
- Department of Cancer Biology, Mayo Clinic, 4500 San Pablo Road S, Jacksonville, FL 32224, USA
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3
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Ailawadhi S, Parrondo RD, Moustafa MA, LaPlant BR, Alegria V, Chapin D, Roy V, Sher T, Paulus A, Chanan-Kahn AA. Ibrutinib, Lenalidomide and Dexamethasone in Patients with Relapsed and/or Refractory Multiple Myeloma: Phase I Trial Results. Hematol Oncol 2022; 40:695-703. [PMID: 35488778 DOI: 10.1002/hon.3012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/07/2022]
Abstract
Therapeutic strategies that target novel pathways are urgently needed for patients with relapsed/refractory multiple myeloma (RRMM). Ibrutinib is an oral covalent inhibitor of Bruton tyrosine kinase, which is overexpressed in MM cells. This phase 1 dose-escalation study examined various doses of ibrutinib in combination with standard doses of lenalidomide (25mg) and dexamethasone (40mg) using a standard 3+3 design in RRMM patients. The primary objective was to determine the maximum tolerated dose (MTD) of ibrutinib in combination with lenalidomide and dexamethasone. Patients (n=15) had received a median of 4 prior regimens, 53% were triple-class exposed, 33% were penta-exposed, and 54% were lenalidomide-refractory. The MTD of ibrutinib was 840mg (n=6) and only 1 dose-limiting toxicity (DLT); a grade 3 rash possibly related to ibrutinib was noted. The most common ≥grade 3 adverse events (AEs) were rash in 2 (13%), lymphopenia in 2(13%), leukopenia, neutropenia, thrombocytopenia, and anemia all occurring in 3 (20%) patients each. One patient achieved a partial response for an overall response rate of 7%. The clinical benefit rate was 80%. The median time to progression was 3.8 months. Ibrutinib, lenalidomide and dexamethasone appears to be a safe and well-tolerated regimen with reasonable efficacy in heavily pretreated RRMM patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sikander Ailawadhi
- Mayo Clinic Cancer Center, Jacksonville, FL, United States.,Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, United States
| | | | | | - Betsy R LaPlant
- Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | | | - Dustin Chapin
- Clinical Studies Unit, Mayo Clinic, Jacksonville, FL, United States
| | - Vivek Roy
- Mayo Clinic Cancer Center, Jacksonville, FL, United States
| | - Taimur Sher
- Mayo Clinic Cancer Center, Jacksonville, FL, United States
| | - Aneel Paulus
- Mayo Clinic Cancer Center, Jacksonville, FL, United States.,Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, United States
| | - Asher A Chanan-Kahn
- Mayo Clinic Cancer Center, Jacksonville, FL, United States.,Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, United States
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Khurana A, Mwangi R, Nowakowski GS, Habermann TM, Ansell SM, LaPlant BR, Link BK, Cerhan JR, Maurer MJ, Witzig TE. Impact of Organ Function-Based Clinical Trial Eligibility Criteria in Patients With Diffuse Large B-Cell Lymphoma: Who Gets Left Behind? J Clin Oncol 2021; 39:1641-1649. [PMID: 33529046 PMCID: PMC8274741 DOI: 10.1200/jco.20.01935] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Exclusion of patients needing urgent treatment or requiring novel biomarkers before enrollment has impacted the ability to enroll real-world patients in frontline trials of diffuse large B-cell lymphoma (DLBCL). The impact of baseline organ function-based eligibility criteria on this effect and clinical trial exclusion is less well-understood. METHODS Consecutive patients with newly diagnosed lymphoma were enrolled from 2002 to 2015 into the Molecular Epidemiology Resource (MER) of the University of Iowa and Mayo Clinic Lymphoma Specialized Program of Research Excellence. The current analysis includes 1,265 patients with DLBCL receiving standard immunochemotherapy. Organ function parameters were identified from criteria for hemoglobin, absolute neutrophil count, platelet count, creatinine clearance, and bilirubin, as reported in frontline DLBCL trials. Abstracted laboratory values from MER were used to determine the percent (%) of patients excluded. Outcomes and cause-of-death analyses comparing ineligible and eligible groups in MER were conducted. An interactive online tool was developed to estimate exclusions based on organ function for future trial design. RESULTS Between 9% and 24% of MER patients with DLBCL receiving standard immunochemotherapy were excluded on the basis of baseline organ function alone. Ineligible patients based on organ function had significantly inferior event-free survival (hazard ratios, 1.67-2.16), overall survival (hazard ratios, 1.87-2.56), and event-free survival at 24 months (odds ratio, 1.71-2.16). Ineligible patients were more likely to die from lymphoma progression than increased therapy-related complications. CONCLUSION Current national and international trials exclude up to 24% of patients from participation on the basis of organ function alone. A significant difference in the outcomes, notably lymphoma-related death, suggests issues with generalization and potential exclusion of high-risk patients. These data will help future clinical trial development and meet US Food and Drug Administration and ASCO recommendations to increase trial accrual.
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Affiliation(s)
| | - Raphael Mwangi
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - Betsy R. LaPlant
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Brian K. Link
- Department of Medicine, University of Iowa, Iowa City, IA
| | - James R. Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Thomas E. Witzig
- Division of Hematology, Mayo Clinic, Rochester, MN,Thomas E. Witzig, MD, Division of Hematology, Mayo Clinic, 200 First Street, Rochester, MN 55905; e-mail:
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5
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Khurana A, Micallef IN, LaPlant BR, Patrick O'Neill B, Habermann TM, Ansell SM, Inwards DJ, Porrata LF, Paludo J, Bisneto JCV, Johnston PB. Outcomes of Autologous Stem Cell Transplant Consolidation in Primary Central Nervous System Lymphoma: A Mayo Clinic Experience. Biol Blood Marrow Transplant 2020; 26:2217-2222. [PMID: 32818553 DOI: 10.1016/j.bbmt.2020.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/04/2020] [Accepted: 08/09/2020] [Indexed: 11/16/2022]
Abstract
A paucity of randomized phase III clinical trials in primary central nervous system lymphoma (PCNSL) has resulted in no uniform consensus on the optimal strategy for consolidation and conditioning regimens for autologous stem cell transplant (ASCT). The past 2 decades have witnessed a preference for thiotepa (TT)-based conditioning regimens due to superior central nervous system penetration. We retrospectively evaluated outcomes of patients with PCNSL who underwent ASCT at Mayo Clinic, Rochester over the past 2 decades, and the impact of TT-based conditioning regimens. Fifty-six patients underwent transplant for PCNSL, with 25 and 31 patients receiving BEAM (non-thiotepa) and carmustine (BCNU)/TT-based conditioning, respectively. All patients received high-dose methotrexate-based induction therapy. While the BCNU/TT group had higher risk disease features such as high International Extranodal Lymphoma Study Group prognostic score, elevated cerebrospinal fluid protein, and older patient population, there was no significant difference at 2 years post-transplant in progression-free survival (BEAM 68.0% [46.1% to 82.5%] versus BCNU/TT, 65.5% [45.2% to 79.8%], P = .99) or overall survival (OS) (84.0% [62.8% to 93.7%] in the BEAM group versus 81.6% [61.3% to 91.9%] in the BCNU/TT group, P = .95). Disease response status before transplant significantly affected the outcomes as those in complete remission had an OS at 2 years post-transplant of 94.7% (68.1% to 99.2%) in the BEAM group and 90.5% (67.0% to 97.5%) in the BCNU/TT group compared with those in partial response, 57.1% (17.2% to 83.7%) in BCNU/TT group and 50.0% (11.1% to 80.4%) in the BEAM group, respectively (P < .0001). Our retrospective cohort adds to the currently available literature and identifies the disease status before transplant as a significant factor affecting survival.
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Affiliation(s)
- Arushi Khurana
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Betsy R LaPlant
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Luis F Porrata
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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6
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St-Pierre F, Broski SM, LaPlant BR, Ristow K, Macon WR, Habermann TM, Witzig TE. Bone involvement on PET/CT predicts event-free survival in follicular lymphoma Grade 3B. Br J Haematol 2020; 191:e41-e43. [PMID: 33460052 DOI: 10.1111/bjh.16974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Stephen M Broski
- Department of Radiology, Division of Nuclear Radiology, Mayo Clinic, Rochester, MN, USA
| | - Betsy R LaPlant
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kay Ristow
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - William R Macon
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Thomas M Habermann
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Thomas E Witzig
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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7
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St-Pierre F, Broski SM, LaPlant BR, Maurer MJ, Ristow K, Thanarajasingam G, Macon WR, Habermann TM, Witzig TE. Fluorodeoxyglucose-Positron Emission Tomography Predicts Bone Marrow Involvement in the Staging of Follicular Lymphoma. Oncologist 2020; 25:689-695. [PMID: 32319706 DOI: 10.1634/theoncologist.2019-0952] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/30/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Standard bone marrow biopsy (BMB) and bone involvement with follicular lymphoma (FL) on positron emission tomography (PET)/computed tomography (CT) both predict early clinical failure in FL. The key clinical question is whether PET/CT findings can obviate the need for BMB. The goal of this study was to determine the value of PET/CT in determining bone involvement in FL, using posterior iliac crest BMB as the gold standard. MATERIALS AND METHODS A total of 548 patients with newly diagnosed grade 1-3A FL were included. The presence, pattern, and location of bone involvement, spleen involvement, and standardized uptake values (SUVs) in the L3 vertebral body were recorded for all patients and compared with the BMB report. RESULTS Excluding patients with focal bone lesions on PET/CT, the sensitivity and specificity of PET/CT in detecting bone or marrow involvement, compared with BMB, were 53% and 88%, respectively. The sensitivity and specificity of spleen involvement on PET/CT in predicting a positive BMB were 55% and 86%, respectively. An L3 SUVmax of less than 2.0 resulted in a negative predictive value (NPV) of 96% for marrow involvement on BMB; an L3 SUVmean below 1.4 resulted in an NPV of 100%. CONCLUSION In newly diagnosed FL, PET/CT-detected bone and splenic involvement is highly specific for a positive BMB, and very low SUV values (<2.0 SUVmax and < 1.4 SUVmean ) in the lumbar spine have a high NPV for a negative BMB. Routine BMB may be obviated in these patients. BMB remains necessary to definitively exclude bone marrow involvement in a large majority of patients with a negative PET. IMPLICATIONS FOR PRACTICE Predicting early clinical failure in follicular lymphoma (FL) is important but difficult. Bone marrow involvement by FL is associated with early clinical failure, and determining this involvement is a key component of the initial staging. This study highlights that in certain patients, positron emission tomography/computed tomography is sufficient in determining bone or marrow involvement, without the need for a confirmatory bone marrow biopsy (BMB). An algorithm is provided based on these findings to help clinicians determine which patients would benefit from BMB and when it can be avoided.
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Affiliation(s)
| | - Stephen M Broski
- Department of Radiology, Division of Nuclear Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Betsy R LaPlant
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Maurer
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kay Ristow
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gita Thanarajasingam
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Macon
- Department of Laboratory Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Habermann
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas E Witzig
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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8
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St‐Pierre F, Broski SM, LaPlant BR, Ristow K, Maurer MJ, Macon WR, Habermann TM, Ansell SM, Thompson CA, Micallef INM, Nowakowski GS, Witzig TE. Detection of extranodal and spleen involvement by FDG-PET imaging predicts adverse survival in untreated follicular lymphoma. Am J Hematol 2019; 94:786-793. [PMID: 31006875 DOI: 10.1002/ajh.25493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/09/2019] [Accepted: 04/16/2019] [Indexed: 01/03/2023]
Abstract
Predicting early clinical failure in patients with untreated follicular lymphoma (FL) is important but difficult. This study aimed to determine the incidence and patterns of extranodal (EN) and spleen disease using PET/CT, and assess their utility in predicting early clinical failure. PET/CT images from 613 cases of untreated FL (2003-2016) were reviewed. The location and number of EN sites, patterns of bone involvement, and splenic involvement were recorded. Outcomes were assessed using event-free survival (EFS), overall survival (OS), and early clinical failure at 24 months (EFS24). So, 49% (301/613) of patients had PET/CT-detected EN involvement, and 28% (171/613) had spleen involvement. The presence of ≥2 EN sites, spleen, bone or soft tissue involvement all predicted failure to achieve EFS24. Presence of ≥2 EN sites and bone involvement pattern were also predictive of OS in a univariate analysis. In a multivariate analysis with FLIPI-2 factors, spleen involvement, pattern of bone involvement, and soft tissue involvement independently predicted a lower EFS (HR 1.49 (1.11-2.00), P = .007; HR 1.71 (1.10-2.65), P = .017; and HR 1.67 (1.06-2.62), P = .026, respectively). When the multivariate analysis was performed using PRIMA-PI factors (marrow and B2M), the number of EN sites was an independent prognostic factor for inferior OS (HR 2.28; P = .05). Baseline PET/CT identifies EN involvement in nearly half of patients with untreated FL. The presence of ≥2 EN sites, bone, soft tissue, or splenic involvement predicts early clinical failure. These results, when combined with other factors, may better identify high-risk patients and guide therapy.
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Affiliation(s)
| | - Stephen M. Broski
- Department of Radiology, Division of Nuclear RadiologyMayo Clinic Rochester Minnesota
| | - Betsy R. LaPlant
- Department of Health Sciences Research, Division of Biomedical Statistics and InformaticsMayo Clinic Rochester Minnesota
| | - Kay Ristow
- Department of Medicine, Division of HematologyMayo Clinic Rochester Minnesota
| | - Matthew J. Maurer
- Department of Health Sciences Research, Division of Biomedical Statistics and InformaticsMayo Clinic Rochester Minnesota
| | - William R. Macon
- Department of Laboratory MedicineMayo Clinic Rochester Minnesota
| | - Thomas M. Habermann
- Department of Medicine, Division of HematologyMayo Clinic Rochester Minnesota
| | - Stephen M. Ansell
- Department of Medicine, Division of HematologyMayo Clinic Rochester Minnesota
| | - Carrie A. Thompson
- Department of Medicine, Division of HematologyMayo Clinic Rochester Minnesota
| | | | | | - Thomas E. Witzig
- Department of Medicine, Division of HematologyMayo Clinic Rochester Minnesota
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Inwards DJ, Fishkin PA, LaPlant BR, Drake MT, Kurtin PJ, Nikcevich DA, Wender DB, Lair BS, Witzig TE. Phase I trial of rituximab, cladribine, and temsirolimus (RCT) for initial therapy of mantle cell lymphoma. Ann Oncol 2019; 30:346. [PMID: 29390098 PMCID: PMC6386023 DOI: 10.1093/annonc/mdx814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Kay NE, LaPlant BR, Pettinger AM, Call TG, Leis JF, Ding W, Parikh SA, Conte MJ, Bowen DA, Shanafelt TD. Cumulative experience and long term follow-up of pentostatin-based chemoimmunotherapy trials for patients with chronic lymphocytic leukemia. Expert Rev Hematol 2018; 11:337-349. [PMID: 29460654 DOI: 10.1080/17474086.2018.1442716] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND 7 regimens of pentostatin based chemoimmunotherapy (CIT) for progressive previously untreated CLL primarily with long term follow-up to update both efficacy and toxicity. RESEARCH DESIGN AND METHODS Prognostic markers including assessment of IGVH and FISH status were done on all. Response rates and 95% binomial confidence intervals were calculated for each regimen and in the combined cohort. Overall survival and treatment-free survival were evaluated using Kaplan-Meier methods. RESULTS The initial CIT trial was pentostatin (2 mgs/m2), cyclophosphamide (600 mg/m2) and rituximab (PCR) but subsequent P based CIT trials with modifications in subsequent trials. The cohort (n = 288) included 52% with unmutated IGVH status and del17p (4.5%) and del11q (14.9%). Toxicity profiles were primarily hematologic and no patient has developed MDS or AML after a median follow-up of 6.4 years. The overall response rate across all trials was found to be over 90% with a 41% complete response rate. We validated that the CLL IPI model segregates progressive CLL patients into 4 risk groups associated with OS and TFS. CONCLUSIONS The high overall and complete response levels in favorable genetic risk CLL along with favorable toxicity profiles provide rationale for consideration of a PC based strategy for previously untreated progressive CLL.
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Affiliation(s)
- Neil E Kay
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Betsy R LaPlant
- b Division of Biomedical Statistics and Informatics, Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | - Adam M Pettinger
- b Division of Biomedical Statistics and Informatics, Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | - Timothy G Call
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Jose F Leis
- c Department of Hematology and Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - Wei Ding
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Sameer A Parikh
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Michael J Conte
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Deborah A Bowen
- a Division of Hematology, Department of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Tait D Shanafelt
- d Division of Hematology , Stanford University School of Medicine , Stanford , CA , USA
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Kay NE, Strati P, LaPlant BR, Leis JF, Nikcevich D, Call TG, Pettinger AM, Lesnick CE, Hanson CA, Shanafelt TD. A randomized phase II trial comparing chemoimmunotherapy with or without bevacizumab in previously untreated patients with chronic lymphocytic leukemia. Oncotarget 2018; 7:78269-78280. [PMID: 27861157 PMCID: PMC5346637 DOI: 10.18632/oncotarget.13412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 11/09/2016] [Indexed: 11/25/2022] Open
Abstract
Bevacizumab is a monoclonal antibody targeting vascular endothelial growth factor (VEGF) with in vitro pro-apoptotic and antiangiogenic effects on chronic lymphocytic leukemia (CLL) cells. As monotherapy in patients with CLL, it has no clinical activity. Here we report the results of an open-label, randomized phase II trial comparing the combination of pentostatin, cyclophosphamide and rituximab (PCR) either without or with bevacizumab (PCR-B) in previously untreated CLL patients. A total of 65 evaluable patients were enrolled, 32 receiving PCR and 33 PCR-B. A higher rate of grade 3-4 cardiovascular toxicity was observed with PCR-B (33% vs. 3%, p < 0.003). Patients treated with PCR-B had a trend for a higher complete remission (CR) rate (54.5% vs 31.3%; p = 0.08), longer progression-free survival (PFS)(p = 0.06) and treatment-free survival (TFS)(p = 0.09). No differences in PFS and TFS by IGHV mutational status were observed with the addition of bevacizumab. A significant post-treatment increase in VEGF levels was observed in the PCR-B arm (29.77 to 57.05 pg/mL); in the PCR-B arm, lower baseline CCL-3 levels were significantly associated with achievement of CR (p = 0.01). In conclusion, the addition of bevacizumab to chemoimmunotherapy in CLL is generally well-tolerated and appears to prolong PFS and TFS.
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Affiliation(s)
- Neil E Kay
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Paolo Strati
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Jose F Leis
- Mayo Clinic College of Medicine, Scottsdale, AZ, USA
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12
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Abeykoon JP, Paludo J, King RL, Ansell SM, Gertz MA, LaPlant BR, Halvorson AE, Gonsalves WI, Dingli D, Fang H, Rajkumar SV, Lacy MQ, He R, Kourelis T, Reeder CB, Novak AJ, McPhail ED, Viswanatha DS, Witzig TE, Go RS, Habermann TM, Buadi FK, Dispenzieri A, Leung N, Lin Y, Thompson CA, Hayman SR, Kyle RA, Kumar SK, Kapoor P. MYD88 mutation status does not impact overall survival in Waldenström macroglobulinemia. Am J Hematol 2018; 93:187-194. [PMID: 29080258 DOI: 10.1002/ajh.24955] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 10/25/2017] [Indexed: 12/22/2022]
Abstract
Waldenström macroglobulinemia (WM) is an immunoglobulin M-associated lymphoma, with majority of cases demonstrating MYD88 locus alteration, most commonly, MYD88L265P . Owing to low prevalence of the wild-type (WT) MYD88 genotype in WM, clinically relevant data in this patient population are sparse, with one study showing nearly a 10-fold increased risk of mortality in this subgroup compared to patients with MYD88L265P mutation. We studied a large cohort of patients with MYD88L265P and MYD88WT WM, evaluated at Mayo Clinic, Rochester, between 1995 and 2016, to specifically assess the impact of these genotypes on clinical course. Of 557 patients, MYD88L265P mutation status, as determined by allele-specific polymerase chain reaction, was known in 219, and 174 (79%) of those exhibited MYD88L265P , 157 of 174 patients had active disease. Of 45 (21%) patients with MYD88WT genotype, 44 had active disease. The estimated median follow-up was 7.0 years; median overall survival was 10.2 years (95% CI: 8.4-16.5) for MYD88L265P versus 13.9 years (95% CI: 6.4-29.3) for the MYD88WT (P = 0.86). The time-to-next therapy from frontline treatment and the presenting features were similar in the two patient populations. For patients with smoldering WM at diagnosis, the median time-to-progression to active disease was 2.8 years (95% CI: 2.2-3.8) in the MYD88L265P cohort and 1.9 years (95% CI: 0.7-3.1) in the MYD88WT cohort (P = 0.21). The frequency of transformation to high-grade lymphoma, or the development of therapy-elated myelodysplastic syndrome was higher in the MYD88WT cohort (16% versus 4% in the MYD88L265P , P = 0.009). In conclusion, MYD88L265P mutation does not appear to be a determinant of outcome, and its presence may not be a disease-defining feature in WM. Our findings warrant external validation, preferably through prospective studies.
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13
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Witzig TE, Johnston PB, LaPlant BR, Kurtin PJ, Pederson LD, Moore Jr DF, Nabbout NH, Nikcevich DA, Rowland KM, Grothey A. Long-term follow-up of chemoimmunotherapy with rituximab, oxaliplatin, cytosine arabinoside, dexamethasone (ROAD) in patients with relapsed CD20+ B-cell non-Hodgkin lymphoma: Results of a study of the Mayo Clinic Cancer Center Research Consortium (MCCRC) MC0485 now known as academic and community cancer research united (ACCRU). Am J Hematol 2017; 92:1004-1010. [PMID: 28614905 DOI: 10.1002/ajh.24824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/07/2017] [Accepted: 06/12/2017] [Indexed: 12/24/2022]
Abstract
Patients with relapsed aggressive non-Hodgkin lymphoma (NHL) are often treated with platinum-based chemoimmunotherapy regimens in preparation for autologous stem cell transplant. We sought to reduce toxicity and maintain efficacy by using oxaliplatin with rituximab, cytarabine and dexamethasone (ROAD) in a phase II clinical trial in patients who had relapsed after one prior regimen. ROAD was delivered q21 days and consisted of rituximab 375 mg/m2 IV weekly x 4 doses (cycle 1 only); dexamethasone 40 mg PO/IV d2 - 5; oxaliplatin 130 mg/m2 IV day 2; cytarabine 2000 mg/m2 IV × two doses on days 2 to 3; and pegfilgrastim 6 mg SC on day 4. Forty-five eligible patients were accrued between 2006 and 2008. Patient characteristics were a median age of 69 years; 96% had received prior rituximab; 53% were within one year of diagnosis. The median number of cycles received was 2 (range, 1-6). Forty-four % received ROAD as an outpatient. The overall response rate was 71% with 27% (12/45) CR and 44% (20/45) PR. Forty-four % (20/45) of all patients and 69% (18/26) of patients whom responded after 2 cycles proceeded to transplant. Median overall survival was 26 mos (95% CI: 7.3 mos-not reached) and median progression-free survival was 11 mos (95% CI: 6-104 mos). There was no grade 3/4 nephrotoxicity; the rate of grade 3/4 neuropathy was 4%. Forty-two percent of all patients and 69% of patients transplanted remain alive at 5 years. ROAD represents an acceptable salvage therapeutic option for patients with relapsed aggressive NHL.
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Affiliation(s)
- Thomas E. Witzig
- Division of Hematology; Department of Medicine, Mayo Clinic Rochester; Rochester Minnesota
| | - Patrick B. Johnston
- Division of Hematology; Department of Medicine, Mayo Clinic Rochester; Rochester Minnesota
| | - Betsy R. LaPlant
- Division of Biomedical Statistics and Bioinformatics; Department of Health Sciences Research, Mayo Clinic Rochester; Rochester Minnesota
| | - Paul J. Kurtin
- Division of Hematopathology; Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester; Rochester Minnesota
| | - Levi D. Pederson
- Division of Biomedical Statistics and Bioinformatics; Department of Health Sciences Research, Mayo Clinic Rochester; Rochester Minnesota
| | | | | | | | | | - Axel Grothey
- Division of Medical Oncology; Mayo Clinic; Rochester Minnesota
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14
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Paludo J, Mikhael JR, LaPlant BR, Halvorson AE, Kumar S, Gertz MA, Hayman SR, Buadi FK, Dispenzieri A, Lust JA, Kapoor P, Leung N, Russell SJ, Dingli D, Go RS, Lin Y, Gonsalves WI, Fonseca R, Bergsagel PL, Roy V, Sher T, Chanan-Khan AA, Ailawadhi S, Stewart AK, Reeder CB, Richardson PG, Rajkumar SV, Lacy MQ. Pomalidomide, bortezomib, and dexamethasone for patients with relapsed lenalidomide-refractory multiple myeloma. Blood 2017; 130:1198-1204. [PMID: 28684537 PMCID: PMC5606008 DOI: 10.1182/blood-2017-05-782961] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 06/21/2017] [Indexed: 01/09/2023] Open
Abstract
This phase 1/2 trial evaluated the maximum tolerated doses, safety, and efficacy of pomalidomide, bortezomib, and dexamethasone (PVD) combination in patients with relapsed lenalidomide-refractory multiple myeloma (MM). In phase 1, dose level 1 consisted of pomalidomide (4 mg by mouth on days 1 to 21), IV or subcutaneous bortezomib (1.0 mg/m2 on days 1, 8, 15, and 22), and dexamethasone (40 mg by mouth on days 1, 8, 15, and 22) given every 28 days. Bortezomib was increased to 1.3 mg/m2 for dose level 2 and adopted in the phase 2 expansion cohort. We describe the results of 50 patients. Objective response rate was 86% (95% confidence interval [CI], 73-94) among all evaluable patients (stringent complete response, 12%; complete response, 10%; very good partial response, 28%; and partial response, 36%) and 100% among high-risk patients. Within a median follow-up of 42 months, 20% remain progression free, 66% are alive, and 4% remain on treatment. Median progression-free survival was 13.7 months (95% CI, 9.6-17.7). The most common toxicities were neutropenia (96%), leukopenia (84%), thrombocytopenia (82%), anemia (74%), and fatigue (72%); however, the majority of these were grade 1 or 2. The most common grade ≥3 toxicities included neutropenia (70%), leukopenia (36%), and lymphopenia (20%). Deep vein thrombosis occurred in 5 patients. In conclusion, PVD is a highly effective combination in lenalidomide-refractory MM patients. Weekly administration of bortezomib enhanced tolerability and convenience. Toxicities are manageable, mostly consisting of mild cytopenias with no significant neuropathy. This trial was registered at www.clinicaltrials.gov as #NCT01212952.
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Affiliation(s)
- Jonas Paludo
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Betsy R LaPlant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alese E Halvorson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | | | - Vivek Roy
- Mayo Clinic Florida, Jacksonville, FL; and
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15
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Ailawadhi S, Mikhael JR, LaPlant BR, Laumann KM, Kumar S, Roy V, Dingli D, Bergsagel PL, Buadi FK, Rajkumar SV, Fonseca R, Gertz MA, Kapoor P, Sher T, Hayman SR, Stewart AK, Dispenzieri A, Kyle RA, Gonsalves WI, Reeder CB, Lin Y, Go RS, Leung N, Kourelis T, Lust JA, Russell SJ, Chanan-Khan AA, Lacy MQ. Pomalidomide-dexamethasone in refractory multiple myeloma: long-term follow-up of a multi-cohort phase II clinical trial. Leukemia 2017; 32:719-728. [PMID: 28860655 DOI: 10.1038/leu.2017.258] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 06/07/2017] [Accepted: 07/05/2017] [Indexed: 11/09/2022]
Abstract
Despite therapeutic advances, multiple myeloma remains incurable, with limited options for patients with refractory disease. We conducted a large, multi-cohort clinical trial testing various doses and treatment schedules of pomalidomide and dexamethasone (Pom/dex) in patients with refractory multiple myeloma. Overall, 345 patients were enrolled to six cohorts based on number and type of prior lines of therapy, pomalidomide dose and schedule. Median prior lines of therapy were three with near universal prior exposure to proteasome inhibitors and/or immunomodulatory drugs. A confirmed response rate of 35% was noted for all cohorts (range 23-65%) with higher responses in cohorts with fewer prior lines of therapy. Median time to confirmed response was ⩽2 months and the longest progression-free survival and overall survival seen in any cohort were 13.1 and 47.9 months, respectively. Observed adverse reactions were as expected, with myelosuppression and fatigue being the most common hematologic and non-hematologic adverse events (AEs), respectively. Longer durations of treatment and response, higher response rates and fewer AEs were noted with the 2 mg pomalidomide dose. This is the longest follow-up data for Pom/dex in refractory multiple myeloma and will help shape the real-world utilization of this regimen.
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Affiliation(s)
- S Ailawadhi
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - J R Mikhael
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - B R LaPlant
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - K M Laumann
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - S Kumar
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - V Roy
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - D Dingli
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - P L Bergsagel
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - F K Buadi
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - S V Rajkumar
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - R Fonseca
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - P Kapoor
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - T Sher
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - S R Hayman
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - A K Stewart
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - R A Kyle
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - W I Gonsalves
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - C B Reeder
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Y Lin
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - R S Go
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - N Leung
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - T Kourelis
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - J A Lust
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - S J Russell
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - A A Chanan-Khan
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - M Q Lacy
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
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16
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Bennani NN, LaPlant BR, Ansell SM, Habermann TM, Inwards DJ, Micallef IN, Johnston PB, Porrata LF, Colgan JP, Markovic SN, Nowakowski GS, Macon WR, Reeder CB, Mikhael JR, Northfelt DW, Ghobrial IM, Witzig TE. Efficacy of the oral mTORC1 inhibitor everolimus in relapsed or refractory indolent lymphoma. Am J Hematol 2017; 92:448-453. [PMID: 28211162 DOI: 10.1002/ajh.24671] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/19/2022]
Abstract
Relapsed indolent lymphoma often becomes refractory to standard chemoimmunotherapy and requires new therapeutic strategies. Targeting the PI3K/mTOR pathway in several types of lymphoma has shown preclinical and clinical efficacy providing the rationale to test this strategy in the treatment of relapsed/refractory indolent lymphomas. We investigated in a phase II open label clinical trial the efficacy and safety of single agent everolimus, an inhibitor of mTORC1, in patients with relapsed/refractory indolent lymphomas. Eligible patients received oral everolimus 10 mg daily on a 28 day-cycle schedule. The primary endpoint was to evaluate the overall response rate (ORR) and safety of single-agent everolimus in this patient population. Fifty-five patients with indolent lymphoma were accrued. The median age was 67 years (range: 33-85) with a median of five prior therapies (range: 1-10). The ORR was 35% (19/55; 95% CI: 24-48%), with complete response unconfirmed in 4% (2/55), and partial response in 31% (17/55). The ORR was 61% (14/23) in the patients with FL. The median time to response was 2.3 months (range: 1.4-14.1), median duration of response of 11.5 months (95%-CI: 5.7-30.4), and a median progression-free survival of 7.2 months (95%-CI: 5.5-12.5). The most common toxicity was hematologic with grades 3-4 anemia, neutropenia, and thrombocytopenia documented in 15% (8/55), 22% (12/55), and 33% (18/55), respectively. There were no cases of febrile neutropenia, and eight patients discontinued therapy because of adverse events. Everolimus monotherapy is a valid therapeutic option in the relapsed and/or refractory indolent non-Hodgkin lymphoma patients and is well tolerated.
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Affiliation(s)
- N. Nora Bennani
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Betsy R. LaPlant
- Division of Biomedical Statistics and Bioinformatics, Department of Health Sciences ResearchMayo Clinic RochesterRochester Minnesota
| | - Stephen M. Ansell
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Thomas. M. Habermann
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - David J. Inwards
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Ivana N. Micallef
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Patrick B. Johnston
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Luis F. Porrata
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Joseph P. Colgan
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Svetomir N. Markovic
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | | | - William R. Macon
- Division of Hematopathology, Department of Laboratory Medicine and PathologyMayo Clinic RochesterRochester Minnesota
| | - Craig B. Reeder
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Joseph R. Mikhael
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Donald W. Northfelt
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Irene M. Ghobrial
- Dana Farber Cancer Institute, Harvard Medical SchoolBoston Massachusetts
| | - Thomas E. Witzig
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
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17
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Sfeir JG, Drake MT, LaPlant BR, Maurer MJ, Link BK, Berndt TJ, Shanafelt TD, Cerhan JR, Habermann TM, Feldman AL, Witzig T. Validation of a vitamin D replacement strategy in vitamin D-insufficient patients with lymphoma or chronic lymphocytic leukemia. Blood Cancer J 2017; 7:e526. [PMID: 28157213 PMCID: PMC5386343 DOI: 10.1038/bcj.2017.9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- J G Sfeir
- Division of Endocrinology, Diabetes, Metabolism and Nutrition Department of Internal Medicine Mayo Clinic, Rochester, MN, USA
| | - M T Drake
- Division of Endocrinology, Diabetes, Metabolism and Nutrition Department of Internal Medicine Mayo Clinic, Rochester, MN, USA
| | - B R LaPlant
- Division of Biomedical Statistics and Informatics Mayo Clinic, Rochester, MN, USA
| | - M J Maurer
- Division of Biomedical Statistics and Informatics Mayo Clinic, Rochester, MN, USA
| | - B K Link
- Holden Comprehensive Cancer Center University of Iowa, Iowa City, IA, USA
| | - T J Berndt
- Mayo Clinic Health Science Research, Rochester, MN, USA
| | - T D Shanafelt
- Mayo Clinic Cancer Center Mayo Clinic, Rochester, MN, USA
| | - J R Cerhan
- Mayo Clinic Health Science Research, Rochester, MN, USA
| | - T M Habermann
- Mayo Clinic Cancer Center Mayo Clinic, Rochester, MN, USA
| | - A L Feldman
- Department of Laboratory Medicine and Pathology Mayo Clinic, Rochester, MN, USA
| | - T Witzig
- Mayo Clinic Cancer Center Mayo Clinic, Rochester, MN, USA
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18
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Strati P, Lanasa M, Call TG, Leis JF, Brander DM, LaPlant BR, Pettinger AM, Ding W, Parikh SA, Hanson CA, Chanan-Khan AA, Bowen DA, Conte M, Kay NE, Shanafelt TD. Ofatumumab monotherapy as a consolidation strategy in patients with previously untreated chronic lymphocytic leukaemia: a phase 2 trial. The Lancet Haematology 2016; 3:e407-14. [DOI: 10.1016/s2352-3026(16)30064-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
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19
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Zent CS, Bowen DA, Conte MJ, LaPlant BR, Call TG. Treatment of relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma with everolimus (RAD001) and alemtuzumab: a Phase I/II study. Leuk Lymphoma 2015; 57:1585-91. [DOI: 10.3109/10428194.2015.1113280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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20
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Larsen JT, Shanafelt TD, Leis JF, LaPlant BR, Call TG, Zent CS, Hanson CA, Erlichman C, Habermann TM, Reeder CB, Bowen DA, Conte M, Boysen JC, Secreto CR, Lesnick CE, Tschumper RC, Jelinek DF, Kay NE, Ding W. Abstract B02: The Akt inhibitor MK-2206 in combination with rituximab and bendamustine demonstrates efficacy in relapsed/refractory chronic lymphocytic leukemia: Updated results from the NCCTG N1087 Alliance study. Mol Cancer Ther 2015. [DOI: 10.1158/1538-8514.pi3k14-b02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: PI3K/Akt activation is downstream of the B cell receptor (BCR) signaling cascade and is critical to mediate the interactions between CLL B-cell and bone marrow stroma which support leukemic survival. MK-2206 is a potent oral allosteric Akt inhibitor and we have demonstrated in vitro synergism with bendamustine (B) to induce CLL apoptosis. MK-2206 selectively abolishes BCR-stimulated cytokines CCL3, CCL4, CCL2, and IL-2Ra and significantly inhibits the BCR signaling pathway (Ding, BJH, 2013). We sought to assess the safety, maximal tolerated dose (MTD) and efficacy of MK-2206 in combination with B-rituximab (BR) in relapsed and refractory CLL/SLL patients in a phase I/II trial (NCCTG N1087 Alliance).
Methods: Previously treated symptomatic CLL/SLL patients with up to 3 prior lines of therapy and ECOG performance status of 0-2 were eligible. Patients with 17p deletion or prior treatment with B were excluded. A standard phase I design was used to determine the MTD of MK-2206 in combination with BR (B 70mg/m2 for 2 days per cycle; R cycle 1: 375 mg/m2, cycle 2-6: 500 mg/m2). Phase II employed the MTD to evaluate safety and efficacy of the combination. Response was evaluated 2 months after the last cycle of therapy per IWCLL 2008 criteria.
Results: 13 patients with a median age of 68 years (range 44-75) and 1.2 prior lines of therapy were treated. CLL FISH showed: del(11q) in 4 (31%), trisomy 12 in 2 (15%), del(13q) in 3 (23%), del(6q) (8%), del(17cen) (8%) and normal results in 2 (15%). IGHV was unmutated in 10 (91%) and mutated in 1 patient (9%) and was missing in 2 cases. ZAP-70 was positive in 8 (73%) and negative in 3 patients (27%). CD38 was positive in 8 (62%) and negative in 5 patients (38%). 70% of patients had received prior chemoimmunotherapy. At 90 mg of MK-2206, 1/6 patients experienced a DLT of grade 3 febrile neutropenia and hemolysis. 2/6 patients on the 135 mg dose experienced a DLT. One patient had grade 3 febrile neutropenia and one patient had a grade 3 acneiform rash. MTD was determined to be MK-2206 90 mg. The most common grade 3/4 adverse events were neutropenia (46%) including febrile neutropenia (23%), diarrhea (15%) and thrombocytopenia (15%). The most common all-grade toxicities were neutropenia (69%), thrombocytopenia (62%), anemia (54%), nausea (54%), diarrhea (39%), rash (38%), and hyperglycemia (31%).
10 patients were treated at 90 mg and 3 patients were treated at the 135 mg dose. The ORR was 92% (n=12). Responses were: 3 CR (23%), 2 CR with incomplete marrow recovery (CRi) (15%), 1 clinical CR (CCR) (8%) without marrow confirmation, 1 nodular partial remission (nPR) (8%), 5 PR (38%), and 1 progressive disease (8%). Median follow-up was 20 months (6-31 months). Median PFS in the CR/CRi group was not reached (NR) with 100% of patients progression free versus 12 months (95% CI 2 months-NR) if CR/CRi was not achieved (p=0.027). Median overall survival was NR in either the CR/CRi or non-CR/CRi groups but 2 deaths occurred in the latter group (p=0.44). One patient developed Richter transformation and died at 15 months and a second patient who had achieved PR died from autoimmune hemolytic anemia and fungal infection at 27 months. Two out of five patients who achieved CR or CRi had bone marrow MRD negative status at the final response evaluation.
Conclusions: The Akt inhibitor MK-2206 administered at 90 mg once weekly in combination with BR is tolerated in patients with relapsed or refractory CLL and compares favorably to BR alone (59% ORR and 9% CR, Fischer, JCO, 2011). An ORR of 92% was observed with a 38% of patients achieving CR or CRi. The trial was terminated prematurely due to withdrawal of sponsor support, however further testing of Akt inhibition is needed given the promising results.
Citation Format: Jeremy T. Larsen, Tait D. Shanafelt, Jose F. Leis, Betsy R. LaPlant, Timothy G. Call, Clive S. Zent, Curtis A. Hanson, Charles Erlichman, Thomas M. Habermann, Craig B. Reeder, Deborah A. Bowen, Michael Conte, Justin C. Boysen, Charla R. Secreto, Connie E. Lesnick, Renee C. Tschumper, Diane F. Jelinek, Neil E. Kay, Wei Ding. The Akt inhibitor MK-2206 in combination with rituximab and bendamustine demonstrates efficacy in relapsed/refractory chronic lymphocytic leukemia: Updated results from the NCCTG N1087 Alliance study. [abstract]. In: Proceedings of the AACR Special Conference: Targeting the PI3K-mTOR Network in Cancer; Sep 14-17, 2014; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(7 Suppl):Abstract nr B02.
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Affiliation(s)
| | | | | | | | | | - Clive S. Zent
- 3University of Rochester Medical Center, Rochester, NY
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Zent CS, Call TG, Bowen DA, Conte MJ, LaPlant BR, Witzig TE, Ansell SM, Weiner GJ. Early treatment of high risk chronic lymphocytic leukemia with alemtuzumab, rituximab and poly-(1-6)-beta-glucotriosyl-(1-3)- beta-glucopyranose beta-glucan is well tolerated and achieves high complete remission rates. Leuk Lymphoma 2015; 56:2373-8. [PMID: 25676035 DOI: 10.3109/10428194.2015.1016932] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Poly-[1-6]-β-glucopyranosyl-[1-3]-β-glucopyranose (PGG) beta glucan is a Saccharomyces cerevisiae derived 1,3/1,6 glucose polymer with innate immune system activation potential. This phase I/II clinical trial enrolled 20 eligible patients with chronic lymphocytic leukemia with high-risk biological markers for early initial treatment with alemtuzumab, rituximab and PGG beta glucan (1-2-4 mg/kg/dose) over 31 days. PGG beta glucan at 4 mg/kg was well tolerated and used for the phase II study. There were three grade 3-4 toxicities at least possibly attributed to treatment. Nineteen (95%) patients responded to treatment with 13 (65%) complete responses. All patients were alive at a median follow-up of 24.4 months (range: 9.5-37). Eleven patients had progressive disease (median 17.6 months, 95% confidence interval [CI]: 9.7, 32.1) and eight patients were retreated (median 35.3 months, 95% CI: 17.9, not reached). We conclude that PGG beta glucan, alemtuzumab and rituximab treatment is tolerable and results in a high complete response rate.
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Affiliation(s)
| | | | | | | | - Betsy R LaPlant
- b Department of Health Sciences Research , Mayo Clinic , Rochester , MN , USA
| | | | | | - George J Weiner
- c Holden Comprehensive Cancer Center and Department of Internal Medicine , University of Iowa , Iowa City , IA , USA
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Sonbol MB, Maurer MJ, Stenson MJ, Allmer C, LaPlant BR, Weiner GJ, Macon WR, Cerhan JR, Witzig TE, Gupta M. Elevated soluble IL-2Rα, IL-8, and MIP-1β levels are associated with inferior outcome and are independent of MIPI score in patients with mantle cell lymphoma. Am J Hematol 2014; 89:E223-7. [PMID: 25164110 DOI: 10.1002/ajh.23838] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/21/2023]
Abstract
Mantle cell lymphoma (MCL) is a unique type of lymphoma with a prognosis intermediate between indolent and aggressive types. The purpose of this study was to study blood cytokine levels in newly diagnosed and relapsed MCL patients with respect to patterns of abnormalities and relationship to the MCL International Prognostic Index (MIPI) score. We analyzed blood levels of 30 cytokines using a multiplex ELISA in 88 patients with newly diagnosed MCL (pre-treatment levels) and 20 with relapsed MCL and compared them with controls without known lymphoma. Elevated cytokine levels were compared with clinical outcome and the MIPI score. In the 88 newly diagnosed MCL patients, we found significantly elevated levels compared with controls of IL-12, IP-10, sIL-2Rα, MIG, IL-1RA, IL-8, MIP-1α, and MIP-1β (all P < 0.05). Of these elevated cytokines, sIL-2Rα, IL-8, MIG, MIP-1α, and MIP-1β were predictive of inferior event-free survival, and sIL-2Rα (HR = 1.94; P = 0.038), IL-8 (HR = 2.17; P = 0.015), and MIP-1β (HR = 2.10; P = 0.016) were independent of MIPI score; only sIL-2Rα (HR = 2.35; P = 0.041) was associated with overall survival after adjustment for MIPI. In the relapsed MCL patient group, the only significantly elevated plasma cytokines that predicted EFS were sIL-2Rα (HR = 2.90; P = 0.04) and IL-8 (HR = 3.75; P = 0.02). Elevated blood levels of sIL-2Rα and the pro-inflammatory cytokines IL-8 and MIP-1β are poor prognostic factors in MCL patients and independent of MIPI score. These factors, if validated, will provide important additions to the MIPI and guide the development of new therapies for patients with elevated levels of these cytokines.
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Affiliation(s)
| | | | | | - Cristine Allmer
- Department of Health Sciences; Mayo Clinic; Rochester Minnesota
| | | | - George J. Weiner
- Department of Internal Medicine; University of Iowa College of Medicine; Iowa City Iowa
| | - William R. Macon
- Department of Laboratory Medicine and Pathology; Mayo Clinic; Rochester Minnesota
| | - James R. Cerhan
- Department of Health Sciences; Mayo Clinic; Rochester Minnesota
| | | | - Mamta Gupta
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Inwards DJ, Fishkin PA, LaPlant BR, Drake MT, Kurtin PJ, Nikcevich DA, Wender DB, Lair BS, Witzig TE. Phase I trial of rituximab, cladribine, and temsirolimus (RCT) for initial therapy of mantle cell lymphoma. Ann Oncol 2014; 25:2020-2024. [PMID: 25057177 DOI: 10.1093/annonc/mdu273] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We conducted this trial to determine the maximum tolerated dose (MTD) of temsirolimus added to an established regimen comprised of rituximab and cladribine for the initial treatment of mantle cell lymphoma. PATIENTS AND METHODS A standard phase I cohort of three study design was utilized. The fixed doses of rituximab and cladribine were 375 mg/m(2) i.v. day 1 and 5 mg/m(2)/day i.v. days 1-5 of a 28-day cycle, respectively. There were five planned temsirolimus i.v. dose levels: 15 mg day 1; 25 mg day 1; 25 mg days 1 and 15; 25 mg days 1, 8 and 15; and 25 mg days 1, 8, 15, and 22. RESULTS Seventeen patients were treated: three each at levels 1-4 and five at dose level 5. The median age was 75 years (52-86 years). Mantle Cell International Prognostic Index (MIPI) scores were low in 6% (1), intermediate in 59% (10), and high in 35% (6) of patients. Five patients were treated at level 5 without dose limiting toxicity. Hematologic toxicity was frequent: grade 3 anemia in 12%, grade 3 thrombocytopenia in 41%, grade 4 thrombocytopenia in 24%, grade 3 neutropenia in 6%, and grade 4 neutropenia in 18% of patients. The overall response rate (ORR) was 94% with 53% complete response and 41% partial response. The median progression-free survival was 18.7 months. CONCLUSIONS Temsirolimus 25 mg i.v. weekly may be safely added to rituximab and cladribine at 375 mg/m(2) i.v. day 1 and 5 mg/m(2)/day i.v. days 1-5 of a 28-day cycle, respectively. This regimen had promising preliminary activity in an elderly cohort of patients with mantle cell lymphoma. CLINICALTRIALSGOV IDENTIFIER NCT00787969.
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Affiliation(s)
- D J Inwards
- Division of Hematology, Mayo Clinic, Rochester.
| | - P A Fishkin
- Illinois Oncology Research Association, Peoria
| | - B R LaPlant
- Division of Endocrinology, Mayo Clinic, Rochester
| | - M T Drake
- Division of Endocrinology, Mayo Clinic, Rochester
| | - P J Kurtin
- Division of Hematopathology, Mayo Clinic, Rochester
| | - D A Nikcevich
- Department of Medical Oncology, Essentia Duluth Clinic, Duluth
| | - D B Wender
- Department of Oncology, Siouxland Hematology-Oncology Associates, Sioux City
| | - B S Lair
- Department of Oncology, Iowa Oncology Research Association, Des Moines, USA
| | - T E Witzig
- Division of Hematology, Mayo Clinic, Rochester
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Baig NA, Taylor RP, Lindorfer MA, Church AK, LaPlant BR, Pettinger AM, Shanafelt TD, Nowakowski GS, Zent CS. Induced resistance to ofatumumab-mediated cell clearance mechanisms, including complement-dependent cytotoxicity, in chronic lymphocytic leukemia. J Immunol 2014; 192:1620-9. [PMID: 24431228 DOI: 10.4049/jimmunol.1302954] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ofatumumab (OFA), a human CD20-targeting mAb, kills B lymphocytes using the innate immune system including complement-dependent cytotoxicity (CDC). The efficacy of OFA in patients with chronic lymphocytic leukemia (CLL) is limited by drug resistance, which is not well characterized. To better understand mechanisms of resistance, we prospectively studied CLL cells isolated from blood samples collected before and after in vivo exposure to the initial dose of OFA therapy in 25 patients undergoing their first treatment for progressive CLL. As previously reported, OFA therapy rapidly decreased the absolute lymphocyte count, CD20 expression by CLL cells, and serum complement levels. We now show that after administration of the first dose of OFA, there was a modest rebound in the absolute lymphocyte count and serum complement levels, but substantial ongoing loss of CD20 expression by CLL cells. These post-OFA treatment CLL cells were highly resistant to OFA-mediated CDC but retained sensitivity to alemtuzumab-mediated CDC in vitro. Posttherapy serum OFA levels correlated inversely with both the amount of pretreatment circulating cell-bound CD20 and with the decrease in this value following treatment. In vitro OFA-mediated CDC did not predict clinical responses, and the patients with first-dose reactions to OFA did not have markers of increased complement activation in vivo. We propose that optimal efficacy of CD20- targeted therapy for CLL requires determining an mAb dose size and frequency that optimizes CLL killing without exceeding the capacity of the cytotoxic mechanisms and thus minimizes loss of CD20 expression in the surviving CLL cells.
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Affiliation(s)
- Nisar A Baig
- Division of Hematology, Mayo Clinic, Rochester, MN 55905
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25
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Witzig TE, Reeder CB, LaPlant BR, Gupta M, Johnston PB, Micallef IN, Porrata LF, Ansell SM, Colgan JP, Jacobsen ED, Ghobrial IM, Habermann TM. A phase II trial of the oral mTOR inhibitor everolimus in relapsed aggressive lymphoma. Leukemia 2010; 25:341-7. [PMID: 21135857 PMCID: PMC3049870 DOI: 10.1038/leu.2010.226] [Citation(s) in RCA: 257] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The phosphatidylinositol 3-kinase signal transduction pathway members are often activated in tumor samples from patients with non-Hodgkin's lymphoma (NHL). Everolimus is an oral agent that targets the raptor mammalian target of rapamycin (mTORC1). The goal of this trial was to learn the antitumor activity and toxicity of single-agent everolimus in patients with relapsed/refractory aggressive NHL. Patients received everolimus 10 mg PO daily. Response was assessed after two and six cycles, and then every three cycles until progression. A total of 77 patients with a median age of 70 years were enrolled. Patients had received a median of three previous therapies and 32% had undergone previous transplant. The overall response rate (ORR) was 30% (95% confidence interval: 20-41%), with 20 patients achieving a partial remission and 3 a complete remission unconfirmed. The ORR in diffuse large B cell was 30% (14/47), 32% (6/19) in mantle cell and 38% (3/8) in follicular grade 3. The median duration of response was 5.7 months. Grade 3 or 4 anemia, neutropenia and thrombocytopenia occurred in 14, 18 and 38% of patients, respectively. Everolimus has single-agent activity in relapsed/refractory aggressive NHL and provides proof-of-concept that targeting the mTOR pathway is clinically relevant.
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Affiliation(s)
- T E Witzig
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Mayo Foundation, Rochester, MN 55905, USA.
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26
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Zent CS, LaPlant BR, Johnston PB, Call TG, Habermann TM, Micallef IN, Witzig TE. The treatment of recurrent/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) with everolimus results in clinical responses and mobilization of CLL cells into the circulation. Cancer 2010; 116:2201-7. [PMID: 20166206 DOI: 10.1002/cncr.25005] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with recurrent/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) often have chemotherapy-resistant disease, resulting in poor prognosis. The aim of this study was to learn if inhibition of the mammalian target of rapamycin (mTOR) would produce tumor responses. METHODS This was a phase 2 study of oral single-agent everolimus (10 mg/day) for recurrent/refractory indolent lymphoid malignancies including CLL. RESULTS Four of 22 patients with CLL (18%; 95% confidence interval, 5%-40%) achieved a partial remission to therapy. An unanticipated finding in this study was an increase in absolute lymphocyte count (ALC) associated with a decrease in lymphadenopathy in 8 (36%) patients. ALC increased a median of 4.8-fold (range, 1.9- to 25.1-fold), and the clinically measurable lymphadenopathy decreased a median of 75.5% (range, 38%-93%) compared with baseline measurements. CONCLUSIONS Everolimus has modest antitumor activity against CLL and can mobilize malignant cells from nodal masses into the peripheral circulation in a subset of CLL patients. Because CLL cells in lymphatic tissue and bone marrow can be more resistant to therapy than circulating CLL cells, the ability of everolimus to mobilize CLL cells into the circulation could be used in combination therapeutic regimens.
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Affiliation(s)
- Clive S Zent
- Division of Hematology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Habermann TM, Thompson CA, LaPlant BR, Bauer BA, Janney CA, Clark MM, Rummans TA, Maurer MJ, Sloan JA, Geyer SM, Cerhan JR. Complementary and alternative medicine use among long-term lymphoma survivors: a pilot study. Am J Hematol 2009; 84:795-8. [PMID: 19894247 DOI: 10.1002/ajh.21554] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
No published survey has specifically addressed the beliefs, knowledge, and usage of complementary and alternative medicine (CAM) in long-term (5-20 years) lymphoma survivors alone. In this pilot project, 95 subjects were randomly selected from a population of 2,475 long-term lymphoma survivors and mailed a questionnaire. The median time from lymphoma diagnosis to completion of the questionnaire was 11 years (range 6-20). Overall, 68% (95% CI: 54-80%) of the long-term lymphoma survivors reported that they have used CAM, a rate higher than the estimated usage rate reported for the general population The most commonly used modalities were chiropractic (39%, 95% CI: 27-53%) and massage therapy (21%, 95% CI: 12-34%). Less than 10% used meditation (5%, 95% CI: 1-15%) and relaxation (7%, 95% CI: 2-17%). In terms of common herbal usage, 5% (95% CI: 1-15%) had used St. John's Wort and 7% (95% CI: 2-17%) had used shark cartilage. Although none of the patients reported that CAM usage was directed specifically towards treating their lymphoma, 4% (95% CI: 0-12%) of patients reported that CAM could cure cancer, and 14% (95% CI: 6-26%) reported that CAM could increase their feeling of control over their health. This pilot study suggests that long-term lymphoma survivors appear to use CAM at a rate higher than the general population. The use of potential agents of risk by the survivors and the lack of access to potentially beneficial modalities highlights the need for further study of CAM in this population.
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Affiliation(s)
- Thomas M Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Ansell SM, Hurvitz SA, Koenig PA, LaPlant BR, Kabat BF, Fernando D, Habermann TM, Inwards DJ, Verma M, Yamada R, Erlichman C, Lowy I, Timmerman JM. Phase I study of ipilimumab, an anti-CTLA-4 monoclonal antibody, in patients with relapsed and refractory B-cell non-Hodgkin lymphoma. Clin Cancer Res 2009; 15:6446-53. [PMID: 19808874 DOI: 10.1158/1078-0432.ccr-09-1339] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE The growth of non-Hodgkin lymphomas can be influenced by tumor-immune system interactions. Cytotoxic T-lymphocyte antigen 4 (CTLA-4) is a negative regulator of T-cell activation that serves to dampen antitumor immune responses. Blocking anti-CTLA-4 monoclonal antibodies improves host resistance to immunogenic tumors, and the anti-CTLA-4 antibody ipilimumab (MDX-010) has clinical activity against melanoma, prostate, and ovarian cancers. EXPERIMENTAL DESIGN We did a phase I trial of ipilimumab in patients with relapsed/refractory B-cell lymphoma to evaluate safety, immunologic activity, and potential clinical efficacy. Treatment consisted of ipilimumab at 3 mg/kg and then monthly at 1 mg/kg x 3 months (dose level 1), with subsequent escalation to 3 mg/kg monthly x 4 months (dose level 2). RESULTS Eighteen patients were treated, 12 at the lower dose level and 6 at the higher dose level. Ipilimumab was generally well tolerated, with common adverse events attributed to it, including diarrhea, headache, abdominal pain, anorexia, fatigue, neutropenia, and thrombocytopenia. Two patients had clinical responses; one patient with diffuse large B-cell lymphoma had an ongoing complete response (>31 months), and one with follicular lymphoma had a partial response lasting 19 months. In 5 of 16 cases tested (31%), T-cell proliferation to recall antigens was significantly increased (>2-fold) after ipilimumab therapy. CONCLUSIONS Blockade of CTLA-4 signaling with the use of ipilimumab is well tolerated at the doses used and has antitumor activity in patients with B-cell lymphoma. Further evaluation of ipilimumab alone or in combination with other agents in B-cell lymphoma patients is therefore warranted.
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Affiliation(s)
- Stephen M Ansell
- Division of Hematology and Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA.
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Roy V, LaPlant BR, Gross GG, Bane CL, Palmieri FM. Phase II trial of weekly nab (nanoparticle albumin-bound)-paclitaxel (nab-paclitaxel) (Abraxane) in combination with gemcitabine in patients with metastatic breast cancer (N0531). Ann Oncol 2008; 20:449-53. [PMID: 19087987 DOI: 10.1093/annonc/mdn661] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Nanoparticle albumin-bound (nab)-paclitaxel has better efficacy and practically eliminates the risk of hypersensitivity reactions associated with solvent-based paclitaxel. We studied weekly nab-paclitaxel and gemcitabine combination in an open-label one-stage, phase II trial in patients with previously untreated metastatic breast cancer (MBC). Nab-paclitaxel (125 mg/m(2)) and gemcitabine (1000 mg/m(2)) were administered on days 1 and 8 of a 21-day cycle until disease progression. Fifty patients were enrolled. Forty (80%) had visceral organ involvement and 30 (60%) had >or= 3 sites of metastases. Four (8%) and 21 (42%) patients had complete and partial responses by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Median duration of response was 6.9 months [95% confidence interval (CI) 5.7, not reached], median progression-free survival (PFS) 7.9 months (95% CI 5.4-10 months), and median overall survival (OS) was not reached. PFS and OS at 6 months were 60% (95% CI 48% to 76%) and 92% (95% CI 85% to 100%), respectively. Therapy was well tolerated. Neutropenia was commonest toxicity (42% and 12% grades 3 and 4 neutropenia). Only one patient developed febrile neutropenia. Significant activity and favorable toxicity profile provides a basis for considering this regimen for further evaluation in phase III trials or in combination with biologic agents.
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Affiliation(s)
- V Roy
- Division of Hematology-Oncology, Mayo Clinic, Jacksonville, FL 32224, USA.
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Zent CS, Secreto CR, LaPlant BR, Bone ND, Call TG, Shanafelt TD, Jelinek DF, Tschumper RC, Kay NE. Direct and complement dependent cytotoxicity in CLL cells from patients with high-risk early-intermediate stage chronic lymphocytic leukemia (CLL) treated with alemtuzumab and rituximab. Leuk Res 2008; 32:1849-56. [PMID: 18584865 PMCID: PMC2588544 DOI: 10.1016/j.leukres.2008.05.014] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2008] [Revised: 05/20/2008] [Accepted: 05/20/2008] [Indexed: 12/14/2022]
Abstract
The mechanism of cytotoxicity of alemtuzumab and rituximab in chronic lymphocytic leukemia (CLL) is not well understood. We obtained fresh CLL cells from early-intermediate stage high-risk patients just prior to treatment with alemtuzumab and rituximab to study mechanisms of action and resistance. Alemtuzumab had minimal direct cytotoxicity but caused significant complement dependent cytotoxicity (CDC) although a subpopulation of CLL cells had intrinsic resistance. Rituximab had no direct cytotoxicity and caused minimal CDC in cells from most patients. These data suggest that CDC has a therapeutic role in patients treated with alemtuzumab and that measures to decrease resistance to CDC could increase efficacy.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Monoclonal, Murine-Derived
- Antibodies, Neoplasm/therapeutic use
- Antineoplastic Agents/therapeutic use
- B-Lymphocytes/immunology
- Cell Survival/drug effects
- Complement C3b/analysis
- Drug Resistance, Neoplasm
- Humans
- In Vitro Techniques
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Neoplasm Staging
- Rituximab
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Affiliation(s)
- Clive S Zent
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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31
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Witzig TE, Geyer SM, Kurtin PJ, Colgan JP, Inwards DJ, Micallef INM, LaPlant BR, Michalak JC, Salim M, Dalton RJ, Moore DF, Reeder CB. Salvage chemotherapy with rituximab DHAP for relapsed non-Hodgkin lymphoma: a phase II trial in the North Central Cancer Treatment Group. Leuk Lymphoma 2008; 49:1074-80. [PMID: 18569634 DOI: 10.1080/10428190801993470] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The aim of this study was to learn the toxicity and efficacy of adding 4 doses of rituximab to a standard platinum-based salvage regimen for relapsed CD20+ B-cell non-Hodgkin lymphoma. Patients were treated with rituximab 375 mg/m(2) days 1,8,15, 22 (cycle 1 only); cisplatin 100 mg/m(2) over 24 h on day 3, cytosine arabinoside 2 g/m(2) IV every 12 h x two doses on day 4, dexamethasone 40 mg PO/IV days 3-6, and G-CSF days 5-14. The ORR was 82% (47/57) with 33% (19/57) complete remissions and 49% (28/57) partial remissions. The duration of response (DR) for the 47 responders was 10.5 months (95% CI: 5.3-16.8). The median time to progression (TTP) was 10.3 months (95% CI: 5.3-14.0), the median event-free survival (EFS) was 5.3 months (95% CI: 3.9-11.0), and the median overall survival was 30.5 months (95% CI: 17.8-60.6). We conclude that rituximab can be safely added to standard DHAP.
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Nowakowski GS, Hoyer JD, Shanafelt TD, Geyer SM, LaPlant BR, Call TG, Jelinek DF, Zent CS, Kay NE. Using smudge cells on routine blood smears to predict clinical outcome in chronic lymphocytic leukemia: a universally available prognostic test. Mayo Clin Proc 2007; 82:449-53. [PMID: 17418074 DOI: 10.4065/82.4.449] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recently developed prognostic tests in early Rai and Binet stage chronic lymphocytic leukemia (CLL) require considerable technologic expertise and are not available worldwide. Smudge cells are CLL cells ruptured during smear preparation. We hypothesized that smudge cell formation is inversely correlated with expression of vimentin, a cytoskeletal protein and prognostic marker, and that the percentage of smudge cells would predict prognosis in CLL. We reviewed the blood smears of 75 patients with previously untreated early and intermediate-stage CLL (Rai stage 0-II) who were seen at the Mayo Clinic in Rochester, Minn, between September 1989 and December 2000. A total of 200 lymphocytes and smudge cells were counted on each slide and the results expressed as a percentage of the total lymphocytes (intact and smudged). The median percentage of smudge cells was 27% (range, 4%-72%). The percentage of smudge cells inversely correlated with vimentin expression (r=-0.57; P=.007). The median percentage of smudge cells was higher in patients with the mutated immunoglobulin heavy chain gene than in those with the unmutated immunoglobulin heavy chain gene (31% vs 13%; P=.02). Patients with less than 30% smudge cells had a median time from diagnosis to initial treatment of 72.7 months, whereas the median time from diagnosis to initial treatment in patients with 30% or more smudge cells was not reached (P=.001). The percentage of smudge cells as a continuous variable correlated with overall survival (P=.04). The estimation of smudge cells on a blood smear could be a universally available prognostic test in early-stage CLL.
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Affiliation(s)
- Grzegorz S Nowakowski
- Division of Hematology, College of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Ballman KV, Buckner JC, Brown PD, Giannini C, Flynn PJ, LaPlant BR, Jaeckle KA. The relationship between six-month progression-free survival and 12-month overall survival end points for phase II trials in patients with glioblastoma multiforme. Neuro Oncol 2007; 9:29-38. [PMID: 17108063 PMCID: PMC1828103 DOI: 10.1215/15228517-2006-025] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 09/01/2006] [Indexed: 11/19/2022] Open
Abstract
Common end points for phase II trials in patients with glioblastoma multiforme (GBM) are six-month progression-free survival (PFS6) and 12-month overall survival (OS12). OS12 can be accurately measured but may be confounded with subsequent therapies upon progression, whereas the converse is true for PFS6. Our goal was to assess the relationship between these end points separately for phase II trials in patients with newly diagnosed GBM and patients with recurrent GBM. Data were pooled from 11 North Central Cancer Treatment Group trials for patients with newly diagnosed GBM (n = 1348). All patients received radiotherapy and pharmaceutical therapy (before, during, or after radiotherapy). Data were pooled from 16 trials that used various pharmaceuticals in treating patients for recurrent GBM (n = 345). All trial regimens were declared nonefficacious by predefined criteria. Overall per-patient concordance was estimated with a kappa statistic. The relationship between OS12 and PFS6 across study arms was assessed by weighted linear regression and Pearson's correlation. Simulation was used to determine the agreement of study outcomes when using PFS6 versus OS12 end points. Cox models with progression status as a time-dependent variable and Kaplan-Meier estimators were used to ascertain the association between progression-free survival status and overall survival. At present, 97% of the patients with newly diagnosed GBM and 95% of those with recurrent GBM have died. The PFS6 and OS12 were 43% and 41%, respectively, for patients with newly diagnosed disease and 9% and 14% for patients with recurrent disease. There was only moderate concordance between the end points on both the patient level and the study level. For the simulation studies, we established phase II efficacy criteria for each end point by using the pooled estimates of OS12 (PFS6) as historical controls. The study decisions made using PFS6 and OS12 were in agreement 88% and 90% of the time for the trials of newly diagnosed and recurrent disease, respectively. Finally, there was a strong association between progression-free survival status and overall survival. PFS6 seems to be a reasonable end point for phase II trials in patients with recurrent glioblastoma.
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Affiliation(s)
- Karla V Ballman
- Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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