[show abstract][hide abstract] ABSTRACT: In a phase II trial, we evaluated chlorambucil and rituximab (CLB-R) as first-line induction treatment with or without R as maintenance for elderly chronic lymphocytic leukemia (CLL) patients. Treatment consisted of eight 28-day cycles of CLB (8 mg/m(2) /day, days 1-7) and R (day 1 of cycle 3, 375 mg/m(2) ; cycles 4-8, 500 mg/m(2) ). Responders were randomized to twelve 8-week doses of R (375 mg/m(2) ) or observation. As per intention-to-treat analysis, 82.4% (95% CI, 74.25-90.46%) of 85 patients achieved a response (OR), 16.5% a complete response (CR), 2.4% a CR with incomplete bone marrow recovery. The OR was similar across Binet stages (A 86.4%, B 81.6%, C 78.6%) and age categories (60-64 years, 92.3%; 65-69, 85.2%; 70-74, 75.0%; ≥75, 81.0%). CLB-R was well tolerated. After a median follow-up of 34.2 months, the median progression-free survival (PFS) was 34.7 months (95% CI, 33.1-39.5). TP53 abnormalities, complex karyotype and low CD20 gene expression predicted lack of response; SF3B1 mutation and BIRC3 disruption low CR rates. IGHV mutations significantly predicted PFS. R maintenance tended towards a better PFS than observation, was safe and most beneficial for patients in partial response and for unmutated IGHV cases. CLB-R represents a promising option for elderly CLL patients.
American Journal of Hematology 01/2014; · 4.00 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background
NOX-A12 is a novel, potent, L-stereoisomer RNA aptamer (Spiegelmer®) that binds and neutralizes CXCL12/SDF-1, a chemokine which attracts and activates immune- and non-immune cells via interaction with its receptors, CXCR4 and CXCR7. The signaling of CXCL12 has been shown to play an important role in the pathophysiology of chronic lymphocytic leukemia (CLL), especially in the interaction of leukemic cells with tissue microenvironment. The therapeutic concept of NOX-A12 is to mobilize these bone marrow- and tissue-resident CLL cells into the blood, thereby removing CLL cells from the nurturing milieu and sensitizing them to cytotoxic drugs such as bendamustine and rituximab (BR).
To date, 19/33 planned patients have been enrolled into a multicenter Phase IIa study of NOX-A12 alone and in combination with BR in relapsed CLL patients. Here we report interim data on PK, PD and preliminary efficacy of a pilot group consisting of 3 cohorts of 3 patients each. In the pilot phase, cohorts received single doses of 1, 2 or 4 mg/kg NOX-A12 alone, respectively, two weeks prior to 6 cycles of combined treatment of NOX-A12 with BR repeated every 28 days. During combination therapy, NOX-A12 was administered 1-2 hours prior to rituximab following a dose titration design for all patients: NOX-A12 doses were increased from 1 mg/kg to 2 mg/kg and 4mg/kg at cycles 1, 2 and 3, respectively. During cycles 4-6, doses of NOX-A12 were kept at the highest individually titrated dose. Bendamustine (70 - 100 mg/m², according to SPC) was given on day 2 and 3 (cycle 1) or 1 and 2 (cycle 2-6), combined with 375 mg/m2 rituximab on day 1 for the first cycle and 500 mg/m2 for subsequent cycles. Tumor response was assessed according to NCI-WG 1996 criteria (updated by iwCLL 2008).
In total, 10 patients were enrolled in the pilot group (one additional patient was enrolled due to one patients’ under dosing). The median age was 69 years (range 57-77) with 8 women and 2 men being included. Median prior therapies were 2 (range 1-2), whereby all patients were bendamustine naïve and 6 patients had received rituximab treatment prior to enrolment. 2, 4 and 4 patients presented at screening with Binet stage A, B, and C, respectively. 8 patients showed at least 1 cytogenetic aberration at the beginning of treatment. Tumor assessments before enrolment and at end of cycles 3 and 6 were evaluated.
Plasma profiles of NOX-A12 in the patient population of the pilot group (Figure 1) were similar to those of healthy volunteers in which a plasma half-life of approximately 38 h was observed. After single doses of NOX-A12, the exposure was dose-linear with peak plasma concentrations of 1.7, 3.5, and 6.7 µM in the corresponding cohorts. CLL cells in the peripheral blood were found to be increased throughout the observational period of 3 days (Figure 2). In all patients presenting with lymphadenopathy, the lymph node size decreased markedly. NOX-A12 as single agent was safe and very well tolerated.
All patients responded to the combination treatment of NOX-A12 and BR (ORR 100%); one patient had to be withdrawn from treatment due to multiple infections during cycle 4 having achieved a partial response (PR). At the end of cycle 6, seven patients (78%) showed a PR and two patients (22%) achieved a complete remission (CR). In combination with BR, NOX-A12 was equally safe and well tolerated.
Proof of principle was achieved as single doses of NOX-A12 reached the expected plasma exposure which translated into an effective and prolonged mobilization of CLL cells into the peripheral blood. In addition, the 100% ORR and 22% CR as well as the virtual absence of additional toxicity on top of BR observed in this pilot group compares very favorably with historical controls. Provided that this promising clinical picture will be maintained in the total sample of 33 patients, further development of this novel anti-CXCL12/SDF-1 Spiegelmer® seems warranted.
[show abstract][hide abstract] ABSTRACT: BACKGROUND: The clinical course of patients with B-cell CLL is often complicated by autoimmune phenomena. The DAT might be positive at some time during the course of the disease in up to 35% of cases. The aim of this retrospective study was to investigate the relationship between the occurrence of a positive DAT and biological features of CLL patients. PATIENTS AND METHODS: In our institution, 146 untreated patients with CLL were studied using the DAT. RESULTS: According to the statistical analysis, a high level of β2-microglobulin and unmutated IgHV emerged as factors significantly related to the presence of DAT positivity. Time to first TFS was significantly shorter in DAT-positive patients. The adverse effect of a DAT positive result was maintained in terms of TFS when patients with mutated IgHV status were excluded from statistical analysis. CONCLUSION: These results suggest that the DAT might provide additional prognostic information regarding patients with IgHV unmutated status.
[show abstract][hide abstract] ABSTRACT: Evaluation of: Weide R, Feiten S, Friesenhahn V et al. Retreatment with bendamustine-containing regimens in patients with relapsed/refractory chronic lymphocytic leukemia and indolent B-cell lymphomas achieves high response rates and some long lasting remissions. Leuk. Lymphoma doi:10.3109/10428194.2012.747679 (2012) (Epub ahead of print). A pattern of relapse followed by further therapy is prevalent in patients with indolent lymphoid malignancies indicating the need for additional effective salvage therapies. Previous therapy, response and duration of response to that therapy are among the most important factors in determining the next therapy. Bendamustine, a bifunctional alkylating agent, has been tested alone or in combination in patients with chronic lymphocytic leukemia and indolent non-Hodgkin's lymphomas. In this article, the authors reported data, collected retrospectively, regarding repeatedly treating patients affected by indolent lymphoid malignancies with bendamustine-including regimens at the moment of relapse. Their experience showed that this drug is effective and manageable even when reused in both settings: chronic lymphocytic leukemia and non-Hodgkin's lymphomas combined with rituximab and/or mitoxantrone. The slow evolution in the treatment of patients with lymphoid malignancies has recently given way to a major revolution. Over the past decade, the availability of novel and active targeted agents, particularly monoclonal antibodies, has engendered major progress in the treatment of both aggressive and indolent lymphoid malignancies. Despite the fact that new therapeutic strategies are relying less on nonspecific cytotoxic drugs and more on targeted agents, a pattern of relapse followed by further therapy is prevalent in patients with indolent lymphoid malignancies, indicating the need for additional effective salvage therapies.
Expert Review of Hematology 06/2013; 6(3):247-50. · 2.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: CLL-like monoclonal B lymphocytosis (MBL) shares common immunophenotype and cytogenetic abnormalities with CLL, from which it is discriminated by a cut-off value of 5x10(9)/l circulating clonal B cells. However, the clonal size amongst MBL is extremely variable and allows discrimination of two distinct entities (High- and Low-count MBL) based on a cut-off value of 0.5x10(9)/l clonal B cells. High-count (HC) MBL is associated with lymphocytosis and progresses to CLL requiring treatment at a rate of 1.1%/year, whereas low-count (LC) MBL is found in the general population only through high-sensitivity techniques and carries limited -if any- risk of progression. We performed an immunogenetic profiling of 333 CLL-like MBL cases supplemented by detailed comparisons with CLL, focusing especially on CLL Rai stage-0 (CLL-0). LC and HC-MBL had similar somatic hypermutation status, yet different IGHV gene repertoires and frequencies of B-cell receptor (BcR) stereotypy. In particular, stereotyped BcRs were infrequent in LC-MBL and often not CLL-specific. In contrast, HC-MBL exhibited clear immunogenetic similarities to CLL-0, extending to the frequent presence of CLL-specific stereotypes. These findings indicate that LC-MBL may not represent a true preleukemic condition, thus differing from HC-MBL/CLL-0 where the identification of factors endowing malignant potential is strongly warranted.
[show abstract][hide abstract] ABSTRACT: Key points Only a complete disruption of TP53 function increases the risk for disease progression in previously treated CLL patientsMiR-34a expression significantly correlates with the predicted TP53 activity in previously treated CLL patients with TP53 abnormalities.
[show abstract][hide abstract] ABSTRACT: The efficacy of bendamustine versus chlorambucil in a phase III trial of previously untreated patients with Binet stage B/C chronic lymphocytic leukaemia (CLL) was re-evaluated after a median observation time of 54 months in May 2010. Overall survival (OS) was analysed for the first time. At follow-up, investigator-assessed complete response (CR) rate (21·0% vs 10·8%), median progression-free survival (21·2 vs 8·8 months; P < 0·0001; hazard ratio 2·83) and time to next treatment (31·7 vs 10·1 months; P < 0·0001) were improved for bendamustine over chlorambucil. OS was not different between groups for all patients or those ≤65 years, >65 years, responders and non-responders. However, patients with objective response or a CR experienced a significantly longer OS than non-responders or those without a CR. Significantly more patients on chlorambucil progressed to second/further lines of treatment compared with those on bendamustine (78·3% vs 63·6%; P = 0·004). The benefits of bendamustine over chlorambucil were achieved without reducing quality of life. In conclusion, bendamustine is significantly more effective than chlorambucil in previously untreated CLL patients, with the achievement of a CR or objective response appearing to prolong OS. Bendamustine should be considered as a preferred first-line option over chlorambucil for CLL patients ineligible for fludarabine, cyclophosphamide and rituximab.
British Journal of Haematology 08/2012; 159(1):67-77. · 4.94 Impact Factor
[show abstract][hide abstract] ABSTRACT: First-line chemoimmunotherapy approaches offer prolonged disease-free survival in patients with chronic lymphocytic leukemia (CLL). Despite the improved results with purine analogs ± cyclophosphamide and rituximab (FCR) the disease remains incurable, and patients with CLL are destined to relapse after primary treatment. The prior therapy administered and the response, and duration of response to that therapy, are among the most important factors in determining the next therapy. Bendamustine, a bifunctional alkylating agent, combined with rituximab (BR) has been tested in patients with relapsed and/or refractory CLL in order to investigate the safety and efficacy of this combination. In conclusion, chemoimmunotherapy with BR showed interesting results, with the exception of patients carrying del(17p). Bendamustine appears to be a good choice for second-line therapy owing to its lack of significant cross-resistance with other alkylating agents or fludarabine.
Expert Review of Hematology 02/2012; 5(1):43-6. · 2.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: Prognostic index for survival estimation by clinical-demographic variables were previously proposed in chronic lymphocytic leukemia (CLL) patients. Our objective was to test in a large retrospective cohort of CLL patients the prognostic power of biological and clinical-demographic variable in a comprehensive multivariate model. A new prognostic index was proposed.
Overall survival and time to treatment in 620 untreated CLL patients were analyzed retrospectively to evaluate the multivariate independence and predictive power of mutational status of immunoglobulin heavy chain variable gene segments (IGHV), high-risk chromosomal aberration such as 17p or 11q deletions, CD38 and ZAP-70 expression, age, gender, Binet stage, β2-microglobulin levels, absolute lymphocyte count and number of lymph node regions.
IGHV mutational status and 17p deletion were the sole biological variables with independent prognostic relevance in a multivariate model for overall survival, which included easily measurable clinical parameters (Binet staging, β2-microglobulin levels) and demographics (age and gender). Analysis of time to treatment in Binet A patients below 70 years of age showed that IGHV was the most important predictor. A novel 6-variable clinical-biological prognostic index was developed and internally validated, which assigned 3 points for Binet C stage, 2 points/each for Binet B stage and for age > 65 years, 1 point/each for male gender, high β2-microglobulin levels, presence of an unmutated IGHV gene status or 17p deletion. Patients were classified at low-risk (score = 0-1; 21%), intermediate-risk (score 2-5; 63% of cases), high-risk (score 6-9; 16% of cases). Projected 5-year overall survival was 98%, 90% and 58% in low-, intermediate- and high-risk groups, respectively. A nomogram for individual patient survival estimation was also proposed.
Data indicate that IGHV mutational status and 17p deletion may be integrated with clinical-demographic variables in new prognostic tools to estimate overall survival.
Journal of Translational Medicine 01/2012; 10:18. · 3.46 Impact Factor
[show abstract][hide abstract] ABSTRACT: By using GRADE system we updated the guidelines for management of CLL issued in 2006 from SIE, SIES and GITMO group. We recommended fludarabine, cyclophosphamide, rituximab (FCR) in younger and selected older patients with a good fitness status, no unfavourable genetics (deletion 17p and/or p53 mutations), and a less toxic treatment in nonfit and elderly patients. In patients without unfavourable genetics, relapsed after 24 months the same initial treatment including rituximab can be considered. In patients with unfavourable genetics, refractory or relapsed within 24 months from a prior fludarabine-based treatment, allogeneic SCT or experimental treatments should be given.
Leukemia research 08/2011; 36(4):459-66. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although combination regimens have improved outcomes over monotherapy in chronic lymphocytic leukemia (CLL), patients eventually relapse. Combined fludarabine, cyclophosphamide, and monoclonal anti-CD52 antibody alemtuzumab (FCC) provided synergistic cytotoxicity with effective clearing of minimal residual disease. This phase 2 study determined FCC efficacy and safety in relapsed/refractory CD52(+) B-CLL after ≥ 1 line of treatment. From January 2005 through June 2008, up to 6 courses of oral fludarabine 40 mg/m² per day, oral cyclophosphamide 250 mg/m² per day, and subcutaneous alemtuzumab (Mab-Campath) 10 mg (increased to 20 mg after first 10-patient cohort) were administered days 1 to 3 every 28 days. The primary objective was overall response rate (ORR); secondary objectives included response duration, time to disease progression, and safety and tolerability. ORR was 67% in 43 patients; 30% achieved complete response. ORR significantly improved with 1 versus ≥ 2 prior therapies (P = .018), and without versus with previous monoclonal antibody treatment (P = .003). Median progression-free survival was 24.4 months, not reached in patients achieving complete response. Median overall survival was 33.6 months. Myelosuppression was the most common adverse event, with a low percentage of cytomegalovirus reactivations and manageable infections. However, close vigilance of opportunistic infections is warranted. FCC provides effective immunotherapy in relapsed/refractory CLL, including in patients with poor-risk prognostic factors.
[show abstract][hide abstract] ABSTRACT: We wish to validate in a multicentric CLL population a nomogram and a risk score recently developed to predict overall survival (OS). Complete records from 1037 CLL patients were retrospectively collected to estimate OS and time to treatment (TTT). Cox models were used to test the independence of age, β-2-microglobulin, absolute lymphocyte count (ALC), sex, Rai stage and number of involved lymph node regions (LNR). Accuracy of prognostic models was tested with the concordance index (c-index). Median follow-up was 5.5 years, with 151 deaths and 475 treated patients. Median OS was not reached (65% survival rate at 13.9 years), median TTT was 6 years. We confirmed the ability of the prognostic score to predict OS and TTT in three risk groups, with results comparable with those reported in the original report. However, ALC and Rai stage were not independent predictors, whereas the Binet staging system, which incorporates LNR variable, showed independent predictive power; furthermore, both 5- and 10-year OS estimates from nomogram were lower compared to real data. When separately analysed, the impact of therapy on OS was not selected as independent predictor of OS in our series. According to these results, we proposed a simpler four-variable model (age, sex, Binet staging, β-2-microglobulin) and a new nomogram. This model had a c-index of 0.78 versus 0.76 of the six-variable model (p = 0.043), showing better predictive accuracy. External validation and refinement are needed on independent data sets, possibly from cancer registry patients' series.
[show abstract][hide abstract] ABSTRACT: Over the past decade, the use of the monoclonal antibody alemtuzumab in chronic lymphocytic leukemia has expanded from administration as a single-agent therapy, into use in combination with fludarabine or rituximab, and further to use as a consolidation agent with the goal of eradicating minimal residual disease. Numerous clinical studies have shown that alemtuzumab is effective as first-line treatment and in patients who have relapsed disease or who are refractory to fludarabine. Despite improvements in response rates and survival compared with combination chemotherapy, there remains some hesitation to incorporate alemtuzumab into management because of known toxicities. Adverse events in patients treated with standard-dose, single-agent alemtuzumab occur at generally predictable time points during treatment and can be managed effectively; this outcome is less established when alemtuzumab is incorporated into combination regimens. Variability in alemtuzumab dosing, route of administration, and duration of therapy has led to inconsistent and sometimes adverse safety consequences. This article presents an overview of clinical studies with alemtuzumab as a single agent, in combination, or in consolidation, with discussion of toxicity and suggestions for ensuring that the efficacious outcomes following alemtuzumab therapy are not outweighed by safety concerns.
Clinical advances in hematology & oncology: H&O 05/2011; 9(5):364-73.
[show abstract][hide abstract] ABSTRACT: Alemtuzumab serum levels and clinical response after subcutaneous administration (10 mg 3 times/week for six weeks) have been explored in 29 chronic lymphocytic leukemia patients receiving the monoclonal antibody as consolidation. Serum concentrations after each administration gradually increased during the first week and more markedly during weeks 2 and 3, approaching the steady-state at week 6. Absorption continued slowly through the tissues for about 2-3 weeks after the last administration, starting to decrease thereafter. Difference between Responders and Non-responders was statistically significant: maximal concentration (Cmax) was 1.69 μg/mL vs. 0.44 μg/mL; concentration before subcutaneous administration (Cpre-dose) on day 15 was 0.7 vs. 0.21 μg/mL, area under curve (AUC0-12h) was 11.09 vs. 2.26 μgxh/mL for Responders and Non-responders, respectively. Higher systemic exposure to alemtuzumab correlated with a better clinical response and minimal residual disease. Results suggest that an adjusted schedule according to serum level could improve clinical outcome of patients receiving subcutaneous alemtuzumab.
[show abstract][hide abstract] ABSTRACT: Advanced age is one of the variables more frequently considered to be associated with an adverse prognosis in Waldenström's macroglobulinemia (WM). In a series of 238 symptomatic and asymptomatic WM patients, we retrospectively identified an age cut-off distinguishing two groups of patients with different outcome in terms of overall survival (OS), disease-specific survival (DSS) and treatment-free survival (TFS). Although for the OS the best cut-off was identified at 65 years with shorter OS for elderly patients, no difference was detected in terms of DSS between the two groups. Furthermore, patients over 65 years showed a longer TFS compared with patients under 65 years. Clinical and laboratory disease characteristics did not significantly differ between the two groups of patients except for β2M level. Therefore, the poorer survival of patients over 65 years at diagnosis should probably be attributed to the higher number of no disease-related deaths and is independent from WM.
[show abstract][hide abstract] ABSTRACT: Several studies demonstrated IGVH mutational status and ZAP70 expression as the most relevant prognostic markers in Chronic Lymphocytic Leukemia (CLL), suggesting the separation of two patient subgroups: with good mutated ZAP70 negative (MTZAP70(-) and poor unmutated ZAP70 positive (UMZAP70(+)) prognosis.
We determined the gene expression of B cells in 112 CLL patients divided into three classes: class 1 with MTZAP70(-), class 2 with UMZAP70(+), and class 3 included both UMZAP70(-) and MTZAP70(+).
We found LPL, AGPAT2, MBOAT1, CHPT1, AGPAT4, PLD1 genes encoding enzymes involved in lipid metabolism overexpressed in UMZAP70(+). In addition, this study identified ARSD, a gene belonging to the sphingolipid metabolism, as a new gene significantly overexpressed in UMZAP70(+) compared to MTZAP70(-). Western blots confirmed that ARSD protein levels were significantly different between the 3 classes of patients and normal controls. Statistical analysis identified a significant correlation between ARSD and IGVH; however, both ARSD protein level and IGVH were independently associated with the need for therapy of CLL patients.
ARSD is a novel prognostic factor as the time to start therapy is shorter in patients with high levels of ARSD protein and sphingolipid metabolism could represent a new biological mechanism in CLL.
Cancer biomarkers: section A of Disease markers 01/2011; 11(1):15-28. · 0.97 Impact Factor
[show abstract][hide abstract] ABSTRACT: Secondary myelodysplasia (MDS) and acute myeloid leukemia (AML) are frequent long term complications in Chronic Lymphocytic Leukemia (CLL) and Waldenström Macroglobulinemia (WM) patients. Although disease-related immune-suppression plays a crucial role in leukemogenesis there is great concern that therapy may further increase the risk of developing these devastating complications.Nucleoside analogs (NA) and alkylating agents are considered appropriate agents in the treatment of both CLL and WM patients. Prolonged immunosuppression related to NA therapy and the incorporation of these agents or their metabolites into DNA, with potentially mutagenic action, leads to speculation that their therapeutic use might be responsible for an increased incidence of second cancer especially when combined with other DNA damaging agents like alkylating agents.In this review the published studies considering the occurrence of secondary MDS and AML in CLL and WM patients are reported and the potential role of chemotherapeutic agents in leukemogenesis is discussed.
Mediterranean Journal of Hematology and Infectious Diseases 01/2011; 3(1):e2011031.
[show abstract][hide abstract] ABSTRACT: Polymorphisms of activating Fc-γ receptors (FCGRs) on natural killer cells and macrophages result in variable affinity for immunoglobulin G1 monoclonal antibodies and subsequently modulate antibody-dependent cellular cytotoxicity (ADCC) activity. Whether single-nucleotide polymorphisms of FCGRs correlate with survival of chronic lymphocytic leukemia (CLL) patients treated with a monoclonal antibody containing regimen is unclear. We assessed the FCGR3A and FCGR2A genotype of patients enrolled in the REACH trial, where patients received fludarabine and cyclophosphamide (FC) or rituximab plus FC (R-FC). FCGR3A and FCGR2A polymorphisms did not demonstrate prognostic significance in the FC arm (P = .42 and P = .64, respectively) or R-FC arm (P = .41 and P = .88, respectively) with respect to progression free survival. Patients with intermediate affinity genotypes (FV and HR) benefited significantly from addition of rituximab (hazard ratio = 0.55 [0.37-0.8 CI]; P = .0017 and hazard ratio = 0.63 [0.44-0.9 CI]; P = .011, respectively). Similar benefit was suggested for patients with high- affinity VV and HH (hazard ratio = 0.86 [0.4-1.84 CI]; P = .7 and hazard ratio = 0.7 [0.41-1.18 CI]; P = .18, respectively) and low-affinity FF and RR (hazard ratio = 0.85 [0.56-1.29 CI]; P = .44 and hazard ratio = 0.82 [0.47-1.42 CI]; P = .48, respectively). Overall, our results suggest that FCGR2A and FCGR3A polymorphisms do not significantly influence the outcomes of relapsed or refractory CLL patients treated with FC or the monoclonal antibody regimen R-FC.