Understanding the role of gaze behaviour and coaching experience in the assessment of youth soccer teams

This study aimed to explore the perceptual-cognitive characteristics of coaches as they assessed team performance in youth soccer. The primary focus was to investigate the alignment between coaches' subjective analyses of team behaviour and objective analyses, while also examining the relationship between coaches' gaze behaviour and their levels of coaching experience, particularly considering the potential differences that may exist among coaches with varying levels of experience. Sixty-five male and female adults with various soccer coaching experience (experienced, novice, other team sport experience, and non-team sport experience) watched five 4-minute videos and assessed team behaviour. These subjective evaluations were compared to objective data obtained from video analysis and GPS, which included measures of completed skills, spatiotemporal characteristics, and passing networks. The participants' fixation duration and frequency were measured for each video clip, and the area around the ball specifically. The study found no significant differences between groups regarding the number of times participants' subjective analysis aligned with the objective data (p = 0.059, ɳ2 = 0.07). However, coaches with soccer coaching experience demonstrated a higher fixation frequency and more revisits to the ball area when compared to participants without soccer experience (p = <.001, ɳ2 = 0.09). The current study offers a unique approach to uncovering soccer coaching expertise by combining objective and subjective evaluations of team performance. In summary, the study reveals that coaching experience did not impact how often coaches subjective analyses matched objective data. However, soccer coaches had distinctive gaze behaviour patterns where they revisited the area around the ball more often.

Lenalidomide, rituximab (R2), and ixazomib for frontline treatment of high risk follicular and indolent non-Hodgkin lymphoma

Lenalidomide and rituximab (R2) is an effective frontline treatment for patients with indolent B-cell non-Hodgkin lymphoma (iNHL). We investigated the safety and efficacy of addition of the proteasome inhibitor ixazomib to R2 for treatment of iNHL through a phase I/II clinical trial for high-risk patients. Twenty patients were enrolled, 18 were treated. The target dose of ixazomib 4 mg weekly was achieved during dose escalation. The most common treatment-related adverse events (AEs) were low grade gastrointestinal, rash, neuropathy, and myalgia/arthralgia. There were 33% grade 2 and 17% grade 3 infections. With median follow-up of 5.2 years, four patients discontinued treatment due to lymphoma progression. Best overall response rate (ORR) was 61.2% [55.6% CR, 5.6% PR): 22.2% had stable disease and 16.7% had disease progression. Kaplan-Meier estimates of progression free and overall survival (OS) were 73% and 87% at 36 months, respectively. R2 can safely be combined with ixazomib for treatment-naïve iNHL patients.

Niraparib plus abiraterone acetate with prednisone in patients with metastatic castration-resistant prostate cancer and homologous recombination repair gene alterations: second interim analysis of the randomized phase III MAGNITUDE trial

BACKGROUND

Patients with metastatic castration-resistant prostate cancer (mCRPC) and BRCA alterations have poor outcomes. MAGNITUDE found patients with homologous recombination repair gene alterations (HRR+), particularly BRCA1/2, benefit from first-line therapy with niraparib plus abiraterone acetate and prednisone (AAP). Here we report longer follow-up from the second prespecified interim analysis (IA2).

PATIENTS AND METHODS

Patients with mCRPC were prospectively identified as HRR+ with/without BRCA1/2 alterations and randomized 1 : 1 to niraparib (200 mg orally) plus AAP (1000 mg/10 mg orally) or placebo plus AAP. At IA2, secondary endpoints [time to symptomatic progression, time to initiation of cytotoxic chemotherapy, overall survival (OS)] were assessed.

RESULTS

Overall, 212 HRR+ patients received niraparib plus AAP (BRCA1/2 subgroup, n = 113). At IA2 with 24.8 months of median follow-up in the BRCA1/2 subgroup, niraparib plus AAP significantly prolonged radiographic progression-free survival {rPFS; blinded independent central review; median rPFS 19.5 versus 10.9 months; hazard ratio (HR) = 0.55 [95% confidence interval (CI) 0.39-0.78]; nominal P = 0.0007} consistent with the first prespecified interim analysis. rPFS was also prolonged in the total HRR+ population [HR = 0.76 (95% CI 0.60-0.97); nominal P = 0.0280; median follow-up 26.8 months]. Improvements in time to symptomatic progression and time to initiation of cytotoxic chemotherapy were observed with niraparib plus AAP. In the BRCA1/2 subgroup, the analysis of OS with niraparib plus AAP demonstrated an HR of 0.88 (95% CI 0.58-1.34; nominal P = 0.5505); the prespecified inverse probability censoring weighting analysis of OS, accounting for imbalances in subsequent use of poly adenosine diphosphate-ribose polymerase inhibitors and other life-prolonging therapies, demonstrated an HR of 0.54 (95% CI 0.33-0.90; nominal P = 0.0181). No new safety signals were observed.

CONCLUSIONS

MAGNITUDE, enrolling the largest BRCA1/2 cohort in first-line mCRPC to date, demonstrated improved rPFS and other clinically relevant outcomes with niraparib plus AAP in patients with BRCA1/2-altered mCRPC, emphasizing the importance of identifying this molecular subset of patients.

Blockade of CCR1 induces a phenotypic shift in macrophages and triggers a favorable antilymphoma activity

Tumor-associated macrophages (TAMs) within the tumor microenvironment (TME) play an important role in tumor growth and progression. TAMs have been involved in producing immunosuppressive TME via various factors; however, the underlying mechanisms remain unclear in B-cell lymphoma, including mantle cell lymphoma (MCL). We identified that chemokine receptor-1 (CCR1) is highly expressed on monocytes (Mo) and macrophages (MΦ), and CCR1 pharmacological inhibition or CCR1 siRNA abolished lymphoma-mediated Mo/MΦ migration in a chemotaxis assay. The deficiency of host CCR1 (CCR1 KO) was associated with decreased infiltration of peritoneal-MΦ compared with WT-CCR1. Functional studies indicated that the genetic depletion of CCR1 or treatment inhibited protumor MΦ (M2-like) phenotype by decreasing CD206 and IL-10 expression. Moreover, CCR1 depletion reprogrammed MΦ toward an MHCII+/TNFα+ immunogenic phenotype. Mechanistically, protumor MΦ driven-IL-10 provides a positive feedback loop to tumor-CCL3 by regulating the CCL3 promoter via STAT1 signaling. Therapeutic in vivo targeting of CCR1 with CCR1 antagonist BX-471 significantly reduced FC-muMCL1 mouse tumors in the syngeneic MCL model by the depletion of M2-TAMs and increased infiltration of cytotoxic CD8+ T cells. Our study established that CCR1 exerts a pivotal role in macrophage programming, thus shaping protumor TME and lymphoma progression. CCR1 inhibition through CCR1 antagonists may be a promising therapeutic strategy to reprogram macrophages in lymphoma-TME and achieve better clinical outcomes in patients.

Follicular lymphoma: The long and winding road leading to your cure?

Follicular lymphoma, the most common indolent lymphoma, though highly responsive to therapy is coupled with multiple relapses for the majority of patients. Advances in biologic understanding of molecular events in lymphoma cells and the tumor microenvironment, along with novel cellular and targeted therapies, suggest this may soon change. Here we first review the development of the molecular concepts and classification of follicular lymphoma, along with therapeutic development of treatments based on chemotherapy plus monoclonal antibodies targeting CD20. We then focus on developments over the last decade in further defining follicular lymphoma pathophysiology, leading to targeted therapeutics, as well as novel immunotherapeutic strategies effective against B cell lymphomas including follicular, particularly patients with advanced stage disease. Additional alterations beyond the hallmark t(14;18) translocation are necessary for development of follicular lymphoma. Epigenetic mutations are almost universally identified in follicular lymphoma, most commonly involving histone-lysine N-methyltransferase 2D (KMT2D, the histone acetyltransferases, cAMP response element-binding protein binding protein (CREBBP) and E1A binding protein P300 (EP300) and the histone methyltransferase enhancer of zeste homologue 2 (EZH2). Mutations are also commonly identified in other proliferation/survival pathways such as B-cell receptor, RAS, mTOR and JAK-STAT pathways, as well as immune escape mutations. The host immune response plays a key role as well, based on studies correlating various immune cell subsets and gene expression signatures with outcomes. Over the last decade, many therapeutic options beyond the commonly used bendamustine-rituximab induction regimen have become available or are being investigated. We focus on these newer agents in the relapsed setting. New antibody-based agents include the naked CD19 directed antibody tafasitamab, the CD79b directed antibody drug conjugate (ADC) polatuzumab vedotin and the CD47 directed antibody magrolimab that targets macrophages rather than FL cells directly. Immune modulation by lenalidomide has moved to earlier lines of therapy and in combinations. Several small molecule inhibitors of proliferation signal pathways involving PI3kinase and BTK have activity against FL. Apoptotic pathway modulators also have activity. With increasing recognition of the high rate of epigenetic mutations in FL, HDAC inhibition has a role. More importantly, the EZH2 inhibitor tazemetostat is FDA approved for FL after 2 prior lines of therapy. The most exciting data currently involve immune attack against follicular lymphoma by chimeric antigen receptor T-cells (CART) or bispecific antibody constructs. Given these multiple potentially non-crossreactive mechanisms, studies of rationally designed combination strategies hold the promise of improving outcomes and possibly cure of follicular lymphoma.

Understanding the Presence of Mental Fatigue in Elite Female Football

Purpose: Previous research investigating the impact of induced mental fatigue in football (soccer) has demonstrated associated performance decrements in physical, technical, tactical and decision-making performance. A common limitation amongst this research is the protocols used to induce mental fatigue which provides low ecological validity, and the inclusion of recreational or sub-elite players. Therefore, understanding the presence of mental fatigue in elite football can provide insight into protocols with greater ecological validity. Methods: The current study used focus groups with 10 elite female football players, focusing on five topics (travel, fixture congestion, receiving tactical information, pre-match routine and pressure to win) related to the perceived causes of mental fatigue in elite football (directed by anecdotal quotes in elite football and research-based theories). Results: Several themes emerged from the data; travel fatigue, inability to switch off from football, fatigue experienced following team meetings, use of pre-match music and internal pressure to succeed. Conclusion: These findings present practical recommendations to reduce mental fatigue in elite football settings, such as considering the timing, content and duration of team meetings, providing players with free time/rest where possible, and considering the modality of coaching instructions during matches.

Alternative strategies for optimizing treatment of chronic lymphocytic leukemia with complex clonal architecture

In silico simulation of pre-clinical and clinical data may accelerate pre-clinical and clinical trial advances, leading to benefits for therapeutic outcomes, toxicity and cost savings. Combining this with clonal architecture data may permit truly personalized therapy. Chronic lymphocytic leukemia (CLL) exhibits clonal diversity, evolution and selection, spontaneously and under treatment pressure. We apply a dynamic simulation model to published CLL clonal architecture data to explore alternative therapeutic strategies, focusing on BTK inhibition. By deriving parameters of clonal growth and death behavior we model continuous vs time-limited ibrutinib therapy, and find that, despite persistence of disease, time to clinical progression may not differ. This is a testable hypothesis. We model IgVH-mutated CLL vs unmutated CLL by varying proliferation and find, based on the limited available data about clonal dynamics after such therapy, that there are differences predicted in response to anti-CD20 efficacy. These models can suggest potential clinical trials, and also indicate what additional data are needed to improve predictions. Ongoing work will expand modeling to agents such as venetoclax and to T cell therapies.

Crystal-storing histiocytes in ascites leading to a diagnosis of plasma cell myeloma

Histiocytes containing multiple needle-shaped eosinophilic crystals visualized in a peritoneal fluid sample during evaluation of a patient for liver transplantation led to the diagnosis of unsuspected IgA kappa myeloma. Crystal-storing histiocytosis is a rare phenomenon typically associated with multiple myeloma and B-cell lymphoproliferative disorders. It can involve almost any anatomic site and can occasionally be seen in body fluid samples.

Dribble Deficit quantifies dribbling speed independently of sprinting speed and differentiates between age categories in pre-adolescent basketball players

The aims of this study were to a) quantify the relationships between sprinting and dribbling speed measured using dribble time and Dribble Deficit and b) assess the difference between age categories in sprinting and dribbling speed in pre-adolescent basketball players. Pre-adolescent, male basketball players (Total, N = 81; Under-10, n = 32, Under-9, n = 49) completed two trials of different tasks including 20-m linear sprints without dribbling, 20-m linear sprints dribbling with dominant and non-dominant hands, and change-of-direction (COD) sprints with and without dribbling. Sprinting time, dribbling time and Dribble Deficit were then calculated for each trial. Spearman rank correlations were used to assess the relationships between outcome measures for Under-9 and Under-10 players separately and combined. The Mann-Whitney U test with effect sizes (ES) was used to assess differences in outcome measures between Under-9 and Under-10 players. Moderate-to-very large significant relationships (p <0.05) between linear and COD sprinting time and dribbling time using dominant and non-dominant hands were found in Under-9, Under-10 and all players combined. Trivial-to-moderate relationships were found between sprinting time and Dribble Deficit in all age categories across linear and COD paths. Quicker performance times (p <0.05) were found for Under-10 compared to Under-9 players in all outcome measures (ES: small-to-moderate), except for COD sprinting time (p >0.05; ES: small). Dribble Deficit measures dribbling speed independently of sprinting speed across linear and COD paths in pre-adolescent basketball players and differentiates between age categories.

Understanding the presence of mental fatigue in English academy soccer players

Research has demonstrated that induced mental fatigue impairs soccer-specific technical, tactical and physical performance in soccer players. The findings are limited by the lack of elite players and low ecological validity of the tasks used to induce mental fatigue, which do not resemble the cognitive demands of soccer. The current study collected survey data from English academy soccer players (n = 256; age groups - U14 - U23), with questions comprising of five themes (descriptors of physical and mental fatigue, travel, education, match-play and fixture congestion). The survey consisted of multiple choice responses, checkboxes and blinded/unblinded (for duration based questions) 0-100 arbitrary unit (AU) slider scales. Listening to music (81.6% of players), using social media (58.3%) and watching videos (34.3%) were the most common pre-match activities. Pre-match subjective mental fatigue was low (18.7±18.8 AU), and most frequently reported at the end of a match (47±26 AU) and remained elevated 24-hours post-match (36±27 AU). Travel (29±24 AU), fixture congestion (44±25 AU) and education (30±26 AU) demonstrated a low to moderate presence of subjective mental fatigue. These findings provide an overview of activities performed by English academy soccer players pre-match, and demonstrate that mental fatigue is experienced as a result of match-play.

Apalutamide and overall survival in non-metastatic castration-resistant prostate cancer

BACKGROUND

In the SPARTAN study, compared with placebo, apalutamide added to ongoing androgen deprivation therapy significantly prolonged metastasis-free survival (MFS) and time to symptomatic progression in patients with high-risk non-metastatic castration-resistant prostate cancer (nmCRPC). Overall survival (OS) results at the first interim analysis (IA1) were immature, with 104 of 427 (24%) events required for planned final OS analysis. Here, we report the results of a second pre-specified interim analysis (IA2).

METHODS

One thousand two hundred and seven patients with nmCRPC were randomized 2 : 1 to apalutamide (240 mg daily) or placebo. The primary end point of the study was MFS. Subsequent therapy for metastatic CRPC was permitted. When the primary end point was met, the study was unblinded. Patients receiving placebo who had not yet developed metastases were offered open-label apalutamide. At IA2, pre-specified analysis of OS was undertaken, using a group-sequential testing procedure with O'Brien-Fleming-type alpha spending function. Safety and second progression-free survival (PFS2) were assessed.

RESULTS

Median follow-up was 41 months. With 285 (67% of required) OS events, apalutamide was associated with an improved OS compared with placebo (HR 0.75; 95% CI 0.59-0.96; P = 0.0197), although the P-value did not cross the pre-specified O'Brien-Fleming boundary of 0.0121. Apalutamide improved PFS2 (HR 0.55; 95% CI 0.45-0.68). At IA2, 69% of placebo-treated and 40% of apalutamide-treated patients had received subsequent life-prolonging therapy for metastatic CRPC. No new safety signals were observed.

CONCLUSION

In patients with nmCRPC, apalutamide was associated with a 25% reduction in risk of death compared with placebo. This OS benefit was observed despite crossover of placebo-treated patients and higher rates of subsequent life-prolonging therapy for the placebo group.

Bacterial community structure and response to nitrogen amendments in Lake Shenandoah (VA, USA)

Microbial processes are critical to the function of freshwater ecosystems, yet we still do not fully understand the factors that shape freshwater microbial communities. Furthermore, freshwater ecosystems are particularly susceptible to effects of environmental change, including influx of exogenous nutrients such as nitrogen and phosphorus. To evaluate the impact of nitrogen loading on the microbial community structure of shallow freshwater lakes, water samples collected from Lake Shenandoah (Virginia, USA) were incubated with two concentrations of either ammonium, nitrate, or urea as a nitrogen source. The potential impact of these nitrogen compounds on the bacterial community structure was assessed via 16S rRNA amplicon sequencing. At the phylum level, the dominant taxa in Lake Shenandoah were comprised of Actinobacteria and Proteobacteria, which were not affected by exposure to the various nitrogen treatments. Overall, there was not a significant shift in the diversity of the bacterial community of Lake Shenandoah with the addition of nitrogen sources, indicating this shallow system may be constrained by other environmental factors.

Comparing the Effects of Three Cognitive Tasks on Indicators of Mental Fatigue

This investigation assessed the impact of three cognitively demanding tasks on cognitive performance, subjective, and physiological indicators of mental fatigue. Following familiarization, participants completed four testing sessions, separated by 48 h. During each session, participants watched a 45-min emotionally neutral documentary (control) or completed one of the following computer tasks: Psychomotor Vigilance Task (PVT); AX-Continuous Performance Test (AX-CPT); or Stroop Task. Mental fatigue was assessed before and at regular periods for 60 min following the 45-min treatments. Cognitive performance was assessed using 3-min PVT, and task performance. Subjective assessments were conducted using the Brunel Mood Scale, and visual analog scales (VAS). Physiological indicators of mental fatigue included electroencephalography (EEG), and heart rate variability (HRV). Subjective ratings of mental fatigue increased from pre to 0-min post in all-treatments, but not the documentary (p < 0.05). Subjective fatigue (VAS) remained higher (p < 0.05) than pretreatment values for 20-, 50-, and 60-min following the PVT, Stroop, and AX-CPT respectively. The cognitively demanding tasks had unclear effects on 3-min PVT, EEG, and HRV assessments. Tasks requiring response inhibition appear to induce fatigue for longer durations than a simple vigilance task. Simple VAS appear to be the most practical method for assessing mental fatigue.

The use of the Körperkoordinationstest für Kinder in the talent pathway in youth athletes: A systematic review

OBJECTIVES

Identifying talented athletes from an early age to accelerate their development requires the investment of substantial resources. Due to the need for multifactorial approaches to talent identification, motor competence assessments are increasingly prevalent in contemporary testing batteries. Therefore, the aim of this review was to evaluate the literature on the use of a product-oriented motor competence assessment tool, the Körperkoordinationstest für Kinder (KTK) in the talent pathway and determine whether it is warranted in such programs.

METHODS

Three electronic databases (i.e. PubMed, SPORTDiscus and Web of Science) were searched for studies that used at least one component of the KTK to assess motor competence for talent detection, identification, development and selection in athletic populations. A total of 21 articles were included in the review, of which seven used the full version of the KTK and 14 used modified versions or individual components of the battery. The quality of included studies was assessed using a modified version of the Joanna Brigg's Institute Critical Appraisal Checklist.

RESULTS

The analysed literature suggests that the KTK can successfully distinguish between athletes of different competition levels and across different sporting domains, however, findings should be interpreted with caution due to the cross-sectional nature of the studies. Furthermore, the moving sideways subtest displayed the greatest discriminative power for athletes of different competition levels. Motor competence was not affected by maturation and did not differ between genders or playing positions.

CONCLUSIONS

Collectively, these findings suggest that the KTK is a useful motor competence assessment in the talent pathway.

Lenalidomide consolidation benefits patients with CLL receiving chemoimmunotherapy: results for CALGB 10404 (Alliance)

Prior to novel targeted agents for chronic lymphocytic leukemia (CLL), the best chemoimmunotherapy regimen in patients with non-del(11q) disease was unclear. The role of lenalidomide was also not defined. This phase 2 study randomized 342 untreated patients with non-del(11q) CLL requiring therapy to fludarabine plus rituximab (FR; n = 123), FR plus lenalidomide consolidation (FR+L; n = 109), or FR plus cyclophosphamide (FCR; n = 110) and compared 2-year progression-free survival (PFS) rates of each to the historical control rate with FC (60%). Patients with del(11q) in at least 20% of pretreatment cells continued with FCR (n = 27) or were reassigned to FCR+L (n = 31) and excluded from the primary analysis. Among non-del(11q) patients, 2-year PFS rates were 64% (90% confidence interval [CI], 57-71; FR), 72% (90% CI, 65-79; FR+L), and 74% (90% CI, 66-80; FCR); FR+L and FCR had rates significantly greater than historical control. Median PFS was significantly shorter with FR compared with FR+L (P = .04) and FCR (P < .001): 43 (95% CI, 33-50), 61 (95% CI, 45-71), and 97 (95% CI, 61 to not reached) months, respectively. Median follow-up was 73 months and median overall survival (OS) was only reached with FCR (101 months; 95% CI, 96 to not reached). With FR+L, the risk of death decreased over time and was lower than with FR at later time points (P = .01), but not significantly different from FCR (P = .21). Future studies incorporating short courses of lenalidomide into other novel treatment regimens are justified.

Early Generated B-1-Derived B Cells Have the Capacity To Progress To Become Mantle Cell Lymphoma-like Neoplasia in Aged Mice

In mice, fetal/neonatal B-1 cell development generates murine CD5⁺ B cells (B1a) with autoreactivity. We analyzed B1a cells at the neonatal stage in a V_H11/D/J_H knock-in mouse line (V_H11t) that generates an autoreactive antiphosphatidylcholine BCR. Our study revealed that antiphosphatidylcholine B1a cells develop in liver, mature in spleen, and distribute in intestine/colon, mesenteric lymph node (mLN), and body cavity as the outcome of B-1 cell development before B-2 cell development. Throughout life, self-renewing B-1 B1a cells circulate through intestine, mesenteric vessel, and blood. The body cavity-deposited B1a cells also remigrate. In old age, some B1a cells proceed to monoclonal B cell lymphocytosis. When neonatal B-1 B1a cells express an antithymocyte/Thy-1 autoreactivity (ATA) BCR transgene in the C.B17 mouse background, ATA B cells increase in PBL and strongly develop lymphomas in aging mice that feature splenomegaly and mLN hyperplasia with heightened expression of CD11b, IL-10, and activated Stat3. At the adult stage, ATA B cells were normally present in the mantle zone area, including in intestine. Furthermore, frequent association with mLN hyperplasia suggests the influence by intestinal microenvironment on lymphoma development. When cyclin D1 was overexpressed by the Eμ-cyclin D1 transgene, ATA B cells progressed to further diffused lymphoma in aged mice, including in various lymph nodes with accumulation of IgM^hiIgD^loCD5⁺CD23^-CD43⁺ cells, resembling aggressive human mantle cell lymphoma. Thus, our findings reveal that early generated B cells, as an outcome of B-1 cell development, can progress to become lymphocytosis, lymphoma, and mantle cell lymphoma-like neoplasia in aged mice.

Androgen receptor mutations in patients with castration-resistant prostate cancer treated with apalutamide

Background

Mutations in the androgen receptor (AR) ligand-binding domain (LBD), such as F877L and T878A, have been associated with resistance to next-generation AR-directed therapies. ARN-509-001 was a phase I/II study that evaluated apalutamide activity in castration-resistant prostate cancer (CRPC). Here, we evaluated the type and frequency of 11 relevant AR-LBD mutations in apalutamide-treated CRPC patients.

Patients and methods

Blood samples from men with nonmetastatic CRPC (nmCRPC) and metastatic CRPC (mCRPC) pre- or post-abiraterone acetate and prednisone (AAP) treatment (≥6 months' exposure) were evaluated at baseline and disease progression in trial ARN-509-001. Mutations were detected in circulating tumor DNA using a digital polymerase chain reaction-based method known as BEAMing (beads, emulsification, amplification and magnetics) (Sysmex Inostics' GmbH).

Results

Of the 97 total patients, 51 had nmCRPC, 25 had AAP-naïve mCRPC, and 21 had post-AAP mCRPC. Ninety-three were assessable for the mutation analysis at baseline and 82 of the 93 at progression. The overall frequency of detected AR mutations at baseline was 7/93 (7.5%) and at progression was 6/82 (7.3%). Three of the 82 (3.7%) mCRPC patients (2 AAP-naïve and 1 post-AAP) acquired AR F877L during apalutamide treatment. At baseline, 3 of the 93 (3.2%) post-AAP patients had detectable AR T878A, which was lost after apalutamide treatment in 1 patient who continued apalutamide treatment for 12 months.

Conclusions

The overall frequency of detected mutations at baseline (7.5%) and progression (7.3%) using the sensitive BEAMing assay was low, suggesting that, based on this assay, AR-LBD mutations such as F877L and T878A are not common contributors to de novo or acquired resistance to apalutamide.

ClinicalTrials.gov identifier

NCT01171898.

Co-expression of MYC and BCL2 predicts poorer outcomes for relapsed/refractory diffuse large B-cell lymphoma with R-ICE and intent to transplant

Diffuse large B-cell lymphoma (DLBCL) with co-expression of MYC and BCL2 protein by immunohistochemistry (IHC) - that is, double-expresser lymphoma (DEL) - is associated with poor outcomes after standard frontline therapy. Less is known about the prognostic impact of DEL in patients with relapsed/refractory disease treated with salvage therapy and autologous stem cell transplantation (ASCT). We analyzed the outcomes of 167 patients with relapsed/refractory DLBCL treated with R-ICE (rituximab, ifosfamide, carboplatin and etoposide), of whom 111 patients (66%) underwent ASCT. Using predefined cutoffs for positivity by IHC at relapse for MYC and BCL2 of ⩾40% and ⩾50% of positive tumor cells, respectively, 26 patients (16%) were categorized as DEL and the rest as non-DEL. Overall and complete response rates to R-ICE did not differ between DEL and non-DEL. With a median follow up of 20 months, the 3-year progression-free survival (PFS) and overall survival (OS) rates for DEL were inferior compared to non-DEL (for PFS: 6% versus 33%, p = 0.044, for OS: 39% versus 56%, p = 0.03). The negative impact of DEL on PFS and OS remained significant on multivariable analysis. In conclusion, positive DEL status predicts poorer outcomes following salvage therapy.

Acquired resistance to venetoclax (ABT-199) in t(14;18) positive lymphoma cells

The chromosomal translocation t(14;18) in follicular lymphoma (FL) is a primary oncogenic event resulting in BCL-2 over-expression. This study investigates activity of the BH3 mimetic venetoclax (ABT-199), which targets BCL-2, and mechanisms of acquired resistance in FL.

The sensitivity of FL cells to venetoclax treatment correlated with BCL-2/BIM ratio. Cells with similar expression of anti-apoptotic proteins, but with higher levels of BIM were more sensitive to the treatment. Venetoclax induced dissociation of BCL-2/BIM complex and a decrease in mitochondrial potential. Interestingly the population of cells that survived venetoclax treatment showed increased p-ERK1/2 and p-BIM (S69), as well as a decrease in total BIM levels. Venetoclax resistant cells initially showed elevated levels of p-AKT and p-Foxo1/3a, a dissociation of BIM/BCL-2/BECLIN1 complex, and a decrease in SQSTM1/p62 level (indicating increased autophagy) together with a slight decline in BIM expression. After stable resistant cell lines were established, a significant reduction of BCL-2 levels and almost total absence of BIM was observed.

The acquisition of these resistance phenotypes could be prevented via selective ERK/AKT inhibition or anti-CD20 antibody treatment, thus highlighting possible combination therapies for FL patients.

Analysis of Radionuclide Deposition Ratios from the Fukushima-Daiichi Incident

This paper will examine deposition patterns of four radionuclides following the Fukushima-Daiichi accident. For nearly 13 d following the event, fission products were released into the environment through planned venting procedures and hydrogen explosions. To assist the government of Japan (GOJ) in the assessment of the releases, the National Nuclear Security Administration's Consequence Management Response Team (CMRT) deployed and took nearly 3 mo of measurements using airborne radiation sensors, fixed monitors, high purity germanium (HPGe) detectors, and health physics survey equipment. From the HPGe detector in-situ results gathered by the CMRT and GOJ teams, the depositions of Cs, Cs, Cs, and I were examined as a function of latitude and longitude. Deposition ratios were calculated to express how each radionuclide was deposited relative to Cs. In addition, the first 30 d of results were compared to the isotopic ratios listed in the Federal Radiological Monitoring and Assessment Center (FRMAC) Dose Assessment Manual Volume 2 Nuclear Power Plant default scenario. This was completed to analyze how the default FRMAC values compared with actual measurements. For Cs:Cs and Cs:Cs (1 wk after shutdown), the ratios were 0.969 ± 0.025 and 0.13 ± 0.007, respectively. These were significantly different from the FRMAC default values of 1.6 and 0.4, but they were of the same order of magnitude. Spatially, larger ratios with high uncertainties were recorded near Tokyo, over 200 km from the accident site. The I to Cs ratios, as expected, decayed exponentially over time but were significantly higher than FRMAC values. Six ratios were greater than 20 within 10 d after shutdown compared to the FRMAC default value of 9.9. In addition, the highest ratios were located less than 75 km to the southwest of the plant. Comparing all the isotopic ratios to the FRMAC manual illustrated differences between the default values and the actual field results. This is at least partly due to the fact that the FRMAC default values are based on an average between a pressurized water reactor and boiling water reactor release. These results of the comparison illustrate that the Assessment Manual default values should only be used when no other data are available.

Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

BACKGROUND

In a phase 1 trial, axicabtagene ciloleucel (axi-cel), an autologous anti-CD19 chimeric antigen receptor (CAR) T-cell therapy, showed efficacy in patients with refractory large B-cell lymphoma after the failure of conventional therapy.

METHODS

In this multicenter, phase 2 trial, we enrolled 111 patients with diffuse large B-cell lymphoma, primary mediastinal B-cell lymphoma, or transformed follicular lymphoma who had refractory disease despite undergoing recommended prior therapy. Patients received a target dose of 2×106 anti-CD19 CAR T cells per kilogram of body weight after receiving a conditioning regimen of low-dose cyclophosphamide and fludarabine. The primary end point was the rate of objective response (calculated as the combined rates of complete response and partial response). Secondary end points included overall survival, safety, and biomarker assessments.

RESULTS

Among the 111 patients who were enrolled, axi-cel was successfully manufactured for 110 (99%) and administered to 101 (91%). The objective response rate was 82%, and the complete response rate was 54%.With a median follow-up of 15.4 months, 42% of the patients continued to have a response, with 40% continuing to have a complete response. The overall rate of survival at 18 months was 52%. The most common adverse events of grade 3 or higher during treatment were neutropenia (in 78% of the patients), anemia (in 43%), and thrombocytopenia (in 38%). Grade 3 or higher cytokine release syndrome and neurologic events occurred in 13% and 28% of the patients, respectively. Three of the patients died during treatment. Higher CAR T-cell levels in blood were associated with response.

CONCLUSIONS

In this multicenter study, patients with refractory large B-cell lymphoma who received CAR T-cell therapy with axi-cel had high levels of durable response, with a safety profile that included myelosuppression, the cytokine release syndrome, and neurologic events. (Funded by Kite Pharma and the Leukemia and Lymphoma Society Therapy Acceleration Program; ZUMA-1 ClinicalTrials.gov number, NCT02348216 .).

Impact of comorbidities on outcomes of elderly patients with diffuse large B-cell lymphoma

International prognostic index (IPI) has remained the primary prognostic tool in diffuse large B cell lymphoma (DLBCL) for more than 20 years. Even though the disease is more common in older population, the impact of comorbidities, dose reductions, and treatment-related adverse events (TAEs) on the outcome in elderly DLBCL patients has not been well established. We studied 413 consecutive patients aged ≥ 60 years who were treated at the Cleveland Clinic. The median age at diagnosis was 69 years, 58% of patients had high IPI score, and 85% had low Charlson comorbidity index (CCI). Forty percent of patients required dose reductions during treatment, 78% achieved CR, and 70% experienced at least one grade II-IV TAE. High IPI score, high CCI, reduced dose chemotherapy, TAE, and hospitalization were significant predictors of death and relapse. In multivariable analysis, high IPI and CCI were independent predictors of overall and progression free survival. A simple model combining IPI and CCI could reliably distinguish three prognostically separate risk groups. Our results suggest that incorporation of CCI in current prognostic models can improve prognostication of older DLBCL patients and CCI might be a valuable tool in evaluating the eligibility of older patients for clinical trial enrollment.

Antibody Drug Conjugates (ADCs): Changing the Treatment Landscape of Lymphoma

OPINION STATEMENT

While strides advancing cancer treatment have made it possible to cure some malignancies, the effort to strike an intricate balance between attaining higher efficacy and lower toxicity has been difficult to accomplish, especially with conventional chemotherapy agents. Introduction of antibody drug conjugates (ADCs) has brought us a step closer to this goal and made it possible to target the cancer cells and to minimize effects on normal tissue. Continued efforts have led to approval of two ADCs for cancer therapy, while many others are in various stages of clinical development. The design of ADCs allows them to be internalized into the cancer cells where the drug payload is released and leads to cell death. The key is to identify targets that are exclusively expressed on malignant cells with minimal or no expression on normal cells, which allows for selective killing of tumor cells. Development and approval of more potent ADCs could change the landscape of cancer therapy and possibly eliminate traditional chemotherapy agents from treatment algorithms. In this review, we discuss the ADCs that are being investigated in early and late stage clinical trials for the treatment of B cell non-Hodgkin lymphoma (NHL).

NK cell dysfunction in chronic lymphocytic leukemia is associated with loss of the mature cells expressing inhibitory killer cell Ig-like receptors

A prospective analysis of natural killer (NK) cell phenotype and function was performed on fresh peripheral blood samples from untreated patients with B-cell chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). Compared to healthy controls, CD56^dim NK cells in CLL patients displayed reduced expression of the NKG2D activating receptor and increased CD27 expression, which indicates declines in mature cells. In addition, NK cells from CLL patients showed reduced degranulation responses toward transformed B cells alone or with rituximab and were more sensitive to activation-induced cell death. We further noted a striking reduction in the frequency and viability of NK cells expressing the inhibitory killer cell Ig-like receptors (KIR)2DL1 and/or KIR3DL1, which progressed over time in most patients. Comparisons between a CLL patient and healthy monozygotic twin were consistent with our results in the larger cohorts. Functional and biomarker alterations were less pronounced on NK cells from SLL patients, which have lower tumor burden in peripheral blood than CLL, but significant reduction in degranulation under ADCC conditions and lower frequency and viability of KIR-expressing NK cells were still evident in SLL. We conclude that mature KIR-expressing NK cells respond to the high circulating B cell tumor burden in CLL, but undergo activation-induced apoptosis. Consequently, CLL patients may benefit from therapies that augment NK cell survival and function.

Long-term outcomes, secondary malignancies and stem cell collection following bendamustine in patients with previously treated non-Hodgkin lymphoma

Despite the long history of bendamustine as treatment for indolent non-Hodgkin lymphoma, long-term efficacy and toxicity data are minimal. We reviewed long-term data from three clinical trials to characterize the toxicity and efficacy of patients receiving bendamustine. Data were available for 149 subjects at 21 sites. The median age was 60 years at the start of bendamustine (range 39-84), and patients had received a median of 3 prior therapies. The histologies included grades 1-2 follicular lymphoma (FL; n = 73), grade 3 FL (n = 23), small lymphocytic lymphoma (n = 20), marginal zone lymphoma (n = 15), mantle cell lymphoma (n = 9), transformed lymphomas (n = 5), lymphoplasmacytic lymphoma (n = 2) and not reported (n = 2). The median event-free survival was 14·1 months. Nine of 12 attempted stem cell collections were successful. With a median follow-up of 8·9 years, 23 patients developed 25 cancers, including 8 patients with myelodysplastic syndrome/acute myeloid leukaemia. These data provide important information regarding the long-term toxicity of bendamustine in previously treated patients. A small but meaningful number of patients achieved durable remissions following bendamustine. These rigorously collected, patient-level, long-term follow-up data provide reassurance that bendamustine or bendamustine plus rituximab is associated with efficacy and safety for patients with relapsed or refractory indolent non-Hodgkin lymphoma.

Neuropathy and efficacy of once weekly subcutaneous bortezomib in multiple myeloma and light chain (AL) amyloidosis

INTRODUCTION

Randomized studies have shown that bortezomib (BTZ) can be given weekly via intravenous (IV) route or twice weekly via subcutaneous (SC) route with lower neuropathy risk and no loss of anti-myeloma efficacy compared to original standard IV twice weekly schedule. Weekly SC should therefore yield the best therapeutic index and is widely used but has not been compared to established administration schedules in the context of a clinical trial.

METHODS

Comprehensive electronic medical record review was done for disease control and neuropathy symptoms of 344 consecutive patients who received their first BTZ-containing regimen for myeloma or AL amyloidosis before or after we changed to SC weekly in December 2010. Univariate and multivariable analyses were carried out that adjusted for age, underlying disease, concurrently used anticancer agents, underlying conditions predisposing to neuropathy, and number of prior regimens compared SC weekly to other schedules.

RESULTS

Fifty-three patients received BTZ SC weekly, 17 SC twice weekly, 127 IV weekly and 147 IV twice weekly. Risk for neuropathy of any grade was higher with other schedules compared to SC weekly (44.3% vs. 26.9%, p = 0.001) while response rate was similar (72.1% vs. 76.6%, respectively, p = 0.15). Multivariable analyses upheld higher neuropathy risk (Odds ratio 2.45, 95% CI 1.26-4.76, p = 0.008) while the likelihood of not achieving a response (= partial response or better) was comparable (Odds ratio 1.25, 95% CI 0.58-2.71, p = 0.56) for other schedules compared to SC weekly, respectively. Lower neuropathy risk translated into longer treatment duration when BTZ was started SC weekly (p = 0.001).

CONCLUSIONS

Weekly SC BTZ has activity comparable to other schedules and causes low rates of neuropathy.

Recommendations for Clinical Trial Development in Mantle Cell Lymphoma

Mantle cell lymphoma (MCL) comprises around 6% of all non-Hodgkin's lymphoma (NHL) diagnoses. In younger patients, age less than 60 to 65 years, aggressive induction often followed by consolidation with autologous stem cell transplant has suggested improved outcomes in this population. Less intensive therapies in older patients often followed by maintenance have been studied or are under active investigation. However, despite recent advances, MCL remains incurable, with a median overall survival of around five years. Patients with high-risk disease have particularly poor outcomes. Treatment varies widely across institutions, and to date no randomized trials comparing intensive vs less intensive approaches have been reported. Although recent data have highlighted the heterogeneity of MCL outcomes, patient assessment for treatment selection has largely been driven by patient age with little regard to fitness, disease biology, or disease risk. One critical advance is the finding that minimal residual disease status (MRD) after induction correlates with long-term outcomes. As such, its use as a potential end point could inform clinical trial design. In order to more rapidly improve the outcomes of MCL patients, clinical trials are needed that prospectively stratify patients on the basis of MCL biology and disease risk, incorporate novel agents, and use MRD to guide the need for additional therapy.

Low Level of Blood CD4+ T Cells Is an Independent Predictor of Inferior Progression-free Survival in Diffuse Large B-cell Lymphoma

BACKGROUND

Tumor-infiltrating immune cells influence diffuse large B-cell lymphoma (DLBCL) outcomes. Relatively little, however, is known about the significance of peripheral blood immune cell numbers on DLBCL behavior.

PATIENTS AND METHODS

In the present study, 43 patients with newly diagnosed DLBCL had pretreatment multiparameter peripheral blood flow cytometry performed to assess the immune cell numbers. These cell numbers were correlated with the outcomes of progression-free survival (PFS) and overall survival.

RESULTS

After follow-up period of 0.8 to 152 months (median, 73), 25 patients (56%) were still alive. As continuous variables on univariate analysis, the predictors of PFS were patient age and absolute CD4 cell count (ACD4C), with the International Prognostic Index (IPI) marginally significant. Age was also a significant predictor of overall survival, and the IPI and ACD4C were marginally significant (P = .08). The 17 patients with a greater ACD4C (≥ 450/mm³) had better 5-year PFS than the 26 with a low ACD4C (88% vs. 50%; P = .02). Multivariable analysis, including age as a continuous variable, IPI group, and ACD4C of 450/mm³ showed that age and ACD4C were significant for PFS (P = .01 and P = .02, respectively).

CONCLUSION

Our data, although from a small series, suggest that the blood ACD4C might be a predictor of PFS for patients with DLBCL, independent of age and the IPI.

Mental Fatigue Impairs Soccer-Specific Physical and Technical Performance

PURPOSE

To investigate the effects of mental fatigue on soccer-specific physical and technical performance.

METHODS

This investigation consisted of two separate studies. Study 1 assessed the soccer-specific physical performance of 12 moderately trained soccer players using the Yo-Yo Intermittent Recovery Test, Level 1 (Yo-Yo IR1). Study 2 assessed the soccer-specific technical performance of 14 experienced soccer players using the Loughborough Soccer Passing and Shooting Tests (LSPT, LSST). Each test was performed on two occasions and preceded, in a randomized, counterbalanced order, by 30 min of the Stroop task (mentally fatiguing treatment) or 30 min of reading magazines (control treatment). Subjective ratings of mental fatigue were measured before and after treatment, and mental effort and motivation were measured after treatment. Distance run, heart rate, and ratings of perceived exertion were recorded during the Yo-Yo IR1. LSPT performance time was calculated as original time plus penalty time. LSST performance was assessed using shot speed, shot accuracy, and shot sequence time.

RESULTS

Subjective ratings of mental fatigue and effort were higher after the Stroop task in both studies (P < 0.001), whereas motivation was similar between conditions. This mental fatigue significantly reduced running distance in the Yo-Yo IR1 (P < 0.001). No difference in heart rate existed between conditions, whereas ratings of perceived exertion were significantly higher at iso-time in the mental fatigue condition (P < 0.01). LSPT original time and performance time were not different between conditions; however, penalty time significantly increased in the mental fatigue condition (P = 0.015). Mental fatigue also impaired shot speed (P = 0.024) and accuracy (P < 0.01), whereas shot sequence time was similar between conditions.

CONCLUSIONS

Mental fatigue impairs soccer-specific running, passing, and shooting performance.

Comparing features extractors in EEG-based cognitive fatigue detection of demanding computer tasks

An electroencephalography (EEG)-based classification system could be used as a tool for detecting cognitive fatigue from demanding computer tasks. The most widely used feature extractor in EEG-based fatigue classification is power spectral density (PSD). This paper investigates PSD and three alternative feature extraction methods, in order to find the best feature extractor for the classification of cognitive fatigue during cognitively demanding tasks. These compared methods are power spectral entropy (PSE), wavelet, and autoregressive (AR). Bayesian neural network was selected as the classifier in this study. The results showed that the use of PSD and PSE methods provide an average accuracy of 60% for each computer task. This finding is slightly improved using the wavelet method which has an average accuracy of 61%. The AR method is the best feature extractor compared with the PSD, PSE and wavelet in this study with accuracy of 75.95% in AX-continuous performance test (AX-CPT), 75.23% in psychomotor vigilance test (PVT) and 76.02% in Stroop task (p-value <; 0.05).

A synthetic peptide targeting the BH4 domain of Bcl-2 induces apoptosis in multiple myeloma and follicular lymphoma cells alone or in combination with agents targeting the BH3-binding pocket of Bcl-2

Bcl-2 inhibits apoptosis by two distinct mechanisms but only one is targeted to treat Bcl-2-positive malignancies. In this mechanism, the BH1-3 domains of Bcl-2 form a hydrophobic pocket, binding and inhibiting pro-apoptotic proteins, including Bim. In the other mechanism, the BH4 domain mediates interaction of Bcl-2 with inositol 1,4, 5-trisphosphate receptors (IP₃Rs), inhibiting pro-apoptotic Ca²⁺ signals. The current anti-Bcl-2 agents, ABT-263 (Navitoclax) and ABT-199 (Venetoclax), induce apoptosis by displacing pro-apoptotic proteins from the hydrophobic pocket, but do not inhibit Bcl-2-IP₃R interaction. Therefore, to target this interaction we developed BIRD-2 (Bcl-2 IP₃ Receptor Disruptor-2), a decoy peptide that binds to the BH4 domain, blocking Bcl-2-IP₃R interaction and thus inducing Ca²⁺-mediated apoptosis in chronic lymphocytic leukemia, multiple myeloma, and follicular lymphoma cells, including cells resistant to ABT-263, ABT-199, or the Bruton’s tyrosine kinase inhibitor Ibrutinib. Moreover, combining BIRD-2 with ABT-263 or ABT-199 enhances apoptosis induction compared to single agent treatment. Overall, these findings provide strong rationale for developing novel therapeutic agents that mimic the action of BIRD-2 in targeting the BH4 domain of Bcl-2 and disrupting Bcl-2-IP₃R interaction.

Pixantrone induces cell death through mitotic perturbations and subsequent aberrant cell divisions

Pixantrone is a novel aza-anthracenedione active against aggressive lymphoma and is being evaluated for use against various hematologic and solid tumors. The drug is an analog of mitoxantrone, but displays less cardiotoxicity than mitoxantrone or the more commonly used doxorubicin. Although pixantrone is purported to inhibit topoisomerase II activity and intercalate with DNA, exact mechanisms of how it induces cell death remain obscure. Here we evaluated the effect of pixantrone on a panel of solid tumor cell lines to understand its mechanism of cell killing. Initial experiments with pixantrone showed an apparent discrepancy between its anti-proliferative effects in MTS assays (short-term) compared with clonogenic assays (long-term). Using live cell videomicroscopy to track the fates of cells, we found that cells treated with pixantrone underwent multiple rounds of aberrant cell division before eventually dying after approximately 5 d post-treatment. Cells underwent abnormal mitosis in which chromosome segregation was impaired, generating chromatin bridges between cells or within cells containing micronuclei. While pixantrone-treated cells did not display γH2AX foci, a marker of DNA damage, in the main nuclei, such foci were often detected in the micronuclei. Using DNA content analysis, we found that pixantrone concentrations that induced cell death in a clonogenic assay did not impede cell cycle progression, further supporting the lack of canonical DNA damage signaling. These findings suggest pixantrone induces a latent type of DNA damage that impairs the fidelity of mitosis, without triggering DNA damage response or mitotic checkpoint activation, but is lethal after successive rounds of aberrant division.

Novel Protein Disulfide Isomerase Inhibitor with Anticancer Activity in Multiple Myeloma

Multiple myeloma cells secrete more disulfide bond-rich proteins than any other mammalian cell. Thus, inhibition of protein disulfide isomerases (PDI) required for protein folding in the endoplasmic reticulum (ER) should increase ER stress beyond repair in this incurable cancer. Here, we report the mechanistically unbiased discovery of a novel PDI-inhibiting compound with antimyeloma activity. We screened a 30,355 small-molecule library using a multilayered multiple myeloma cell-based cytotoxicity assay that modeled disease niche, normal liver, kidney, and bone marrow. CCF642, a bone marrow-sparing compound, exhibited a submicromolar IC50 in 10 of 10 multiple myeloma cell lines. An active biotinylated analog of CCF642 defined binding to the PDI isoenzymes A1, A3, and A4 in MM cells. In vitro, CCF642 inhibited PDI reductase activity about 100-fold more potently than the structurally distinct established inhibitors PACMA 31 and LOC14. Computational modeling suggested a novel covalent binding mode in active-site CGHCK motifs. Remarkably, without any further chemistry optimization, CCF642 displayed potent efficacy in an aggressive syngeneic mouse model of multiple myeloma and prolonged the lifespan of C57BL/KaLwRij mice engrafted with 5TGM1-luc myeloma, an effect comparable to the first-line multiple myeloma therapeutic bortezomib. Consistent with PDI inhibition, CCF642 caused acute ER stress in multiple myeloma cells accompanied by apoptosis-inducing calcium release. Overall, our results provide an illustration of the utility of simple in vivo simulations as part of a drug discovery effort, along with a sound preclinical rationale to develop a new small-molecule therapeutic to treat multiple myeloma. Cancer Res; 76(11); 3340-50. ©2016 AACR.

Cyclin E/Cdk2-dependent phosphorylation of Mcl-1 determines its stability and cellular sensitivity to BH3 mimetics

Cyclin E/Cdk2 kinase activity is frequently deregulated in human cancers, resulting in impaired apoptosis. Here, we show that cyclin E/Cdk2 phosphorylates and stabilizes the pro-survival Bcl-2 family protein Mcl-1, a key cell death resistance determinant to the small molecule Bcl-2 family inhibitors ABT-199 and ABT-737, mimetics of the Bcl-2 homology domain 3 (BH3). Cyclin E levels were elevated and there was increased association of cyclin E/Cdk2 with Mcl-1 in ABT-737-resistant compared to parental cells. Cyclin E depletion in various human tumor cell-lines and cyclin E-/- mouse embryo fibroblasts showed decreased levels of Mcl-1 protein, with no change in Mcl-1 mRNA levels. In the absence of cyclin E, Mcl-1 ubiquitination was enhanced, leading to decreased protein stability. Studies with Mcl-1 phosphorylation mutants show that cyclin E/Cdk2-dependent phosphorylation of Mcl-1 residues on its PEST domain resulted in increased Mcl-1 stability (Thr92, and Thr163) and Bim binding (Ser64). Cyclin E knock-down restored ABT-737 sensitivity to acquired and inherently resistant Mcl-1-dependent tumor cells. CDK inhibition by dinaciclib resulted in Bim release from Mcl-1 in ABT-737-resistant cells. Dinaciclib in combination with ABT-737 and ABT-199 resulted in robust synergistic cell death in leukemic cells and primary chronic lymphocytic leukemia patient samples. Collectively, our findings identify a novel mechanism of cyclin E-mediated Mcl-1 regulation that provides a rationale for clinical use of Bcl-2 family and Cdk inhibitors for Mcl-1-dependent tumors.