Health-related quality of life outcomes associated with zanubrutinib versus ibrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia and small lymphocytic lymphoma: results from the ALPINE Trial

The purpose of this analysis was to assess health-related quality of life (HRQoL) in patients treated with zanubrutinib and ibrutinib in the ALPINE trial (NCT03734016). HRQoL was measured by the EORTC QLQ-C30 and EQ-5D-5L at baseline, cycle 1, and every third cycle until end of treatment. Key patient-reported outcome (PRO) endpoints included global health status (GHS), physical and role functioning, as well as symptoms of fatigue, pain, diarrhea, and nausea/vomiting. A mixed model repeated-measure analysis using key PRO endpoints at key clinical cycles (cycles 7 and 13) was performed. 652 patients were randomized to receive zanubrutinib (n = 327) or ibrutinib (n = 325). By cycle 7, GHS scores improved with zanubrutinib versus ibrutinib, and in cycle 13, GHS scores remained higher in the zanubrutinib arm. The zanubrutinib arm experienced clinically meaningful improvements in physical and role functioning, as well as pain and fatigue symptoms at both cycles. Patients in the zanubrutinib arm reported lower diarrhea scores. Nausea/vomiting scores maintained in both arms. EQ-VAS scores showed greater improvement from baseline at both cycle 7 (7.92 versus 3.44) and cycle 13 (7.75 versus 3.92) of treatment with zanubrutinib compared to ibrutinib, respectively. Patients with R/R CLL/SLL treated with zanubrutinib demonstrated improvement versus ibrutinib in the GHS scale at cycle 7. Other endpoints continued to improve, suggesting treatment with zanubrutinib positively affected HRQoL over time. Given the generally good HRQoL at baseline in both arms, the differences between the arms were not significant.</p

P1446A induces JNK and p38 MAPK in CLL cells.

<p><i>(A-D)</i> CLL cells obtained from four individual patients were incubated with P1446A (0.5–1.5 μM) for 4 or 8 hours. Whole-cell protein lysates were subjected to immunoblotting. Representative images and densitometry data are shown. For densitometry, a fold increase in expression of pATF2 (C) and pJNK/cPARP (D) referenced to total levels of protein at each dose and time point were normalized to their expression in untreated samples <i>(E)</i> CLL cells obtained from six individual patients were incubated with 20 μM JNK inhibitor VIII, 20 μM SP600125, 10 μM SB203580 or vehicle control for 1 hour and then with 1 μM P1446A for 24 hours. Apoptosis was determined by Annexin V and 7-AAD staining within the CD19⁺ subset of cells. *–p<0.05; **—p<0.01 vs. control. <i>(F)</i> CLL cells were transfected with siRNA's against ASK1 or control siRNA using Amaxa program X-05 and subsequently incubated with 1 μM P1446A or vehicle control for 24 h. Whole-cell lysates were subjected to immunoblotting. A representative blot of four independent experiments is shown, along with densitometry data (*- p<0.05 vs. control). <i>(G)</i> CLL cells were incubated with 1 μM P1446A or vehicle control for 6 hours. Protein lysates were incubated with antibody against ASK1 or isotype control (not shown) and subjected to immunoblotting. A representative blot of three independent experiments is shown.</p

The UPR in response to P1446A treatment is limited.

<p><i>(A</i>, <i>B)</i> CLL cells obtained from four individual patients were incubated with P1446A (0.5–1.5 μM) for the indicated time intervals. Whole-cell protein lysates were subjected to immunoblotting. Representative images from 1 of 3 independent experiments are shown. <i>(C)</i> Cells were incubated with the indicated concentration of P1446A or 1 μM thapsigargin (thap) for 6 hours, total RNA was isolated, reverse-transcribed and subjected to PCR using XBP1-specific primers.</p

P1446A inhibits interphase CDKs in CLL B-cells.

<p><i>(A-C)</i> CLL cells were incubated with P1446A at the indicated concentrations for 4 or 8 hours. As a control, cells were incubated with dinaciclib for 4 hours. Whole-cell protein lysates were subjected to immunoblotting. Representative images and densitometry data from four individual patients are shown. *- p<0.05 compared to untreated control. (<i>D</i>) CLL cells from 6 individual patients were incubated with 0–1.5 μM P1446A for 6 hours. Total RNA was isolated from CD19⁺ CLL B-cells, reverse-transcribed and subjected to real-time PCR with the indicated probes (in duplicates). Results were normalized to 18S levels. Data are the mean ± SE.</p

Health-related quality of life in treatment-naive CLL/SLL patients treated with zanubrutinib versus bendamustine plus rituximab

Zanubrutinib is a highly selective, next-generation Bruton’s tyrosine kinase inhibitor. In the phase 3 SEQUOIA trial (NCT03336333), treatment with zanubrutinib resulted in significantly improved progression-free survival compared to bendamustine plus rituximab (BR) in adult patients with treatment-naïve chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) without del(17p). The current analysis compared the effects of zanubrutinib versus BR on patients’ health-related quality of life (HRQoL). In the SEQUOIA trial, patient-reported outcomes (PROs) were assessed at baseline and every 12 weeks (3 cycles) using the EORTC QLQ-C30 and EQ-5D-5L. Descriptive analyses were performed on all the questionnaires’ scales and a mixed model for repeated measures was performed using the key QLQ-C30 endpoints of global health status/QoL (GHS/QoL), physical and role functioning, and symptoms of fatigue, pain, diarrhea, and nausea/vomiting at Weeks 12 and 24. Compared with BR-treated patients, those in the zanubrutinib arm experienced greater improvements in HRQoL outcomes at both Weeks 12 and 24. By Week 24, mean change differences (95% confidence interval) between the arms were significant for GHS/QoL (4.9 [0.9, 9.0]), physical functioning (3.8 [0.8, 6.7]), diarrhea (-6.2 [-10.0, -2.5]), fatigue (-4.5 [-8.9, -0.1]), and nausea/vomiting (-4.5 [-8.9, -0.1]); role functioning (4.8 [-0.2, 9.7]) was marginally better in the zanubrutinib arm and there were no differences in pain symptoms (-0.4 [-4.3, 5.1]) between the arms. During the first 24 weeks of treatment, zanubrutinib was associated with better HRQoL outcomes in patients with treatment-naive CLL/SLL without del(17p) compared to BR.</p

P1446A induces NOXA and cooperates with ABT-737 to reverse apoptosis resistance.

<p><i>(A-B)</i> CLL cells from 6 individual patients were incubated with the indicated doses of P1446A for 6 hours with or without 20 μM SP600125. Total RNA was isolated from CD19⁺ CLL B-cells, reverse-transcribed and subjected to real-time PCR with the indicated probes (in duplicates). Results were normalized to 18S levels. Data are the mean ± SE. <i>(C)</i> CLL cells (N = 3) were incubated with 20 μM SP600125 or vehicle control for 1 hour and then with 1 μM P1446A for 6 hours. Whole-cell protein lysates were subjected to immunoblotting. <i>(D)</i> CLL cells (N = 6) were co-cultured with CD40L-expressing stroma for 24 hours and subsequently incubated with the indicated doses of P1446A and ABT-737 or vehicle control for 24 hours. Apoptosis was determined by Annexin V and 7-AAD staining within the CD19⁺ subset of cells. **—p<0.01 vs. control.</p

CDK inhibitor P1446A induces apoptosis of the CLL B-cells independent of <i>IGHV</i> mutational status and cytogenetics.

<p><i>(A)</i> PBMC's from patients with CLL (N = 10) were incubated with 0.05–5 μM P1446A or vehicle control for 24 hours and assayed for apoptosis. Here and subsequently, apoptosis was determined by Annexin V staining within the CD19⁺ subset of cells. Horizontal lines represent the mean. <i>(B)</i> CLL B-cells were incubated with 0.05–1.5 μM P1446A for 24 hours. IC₅₀ value was determined for CLL samples with mutated (N = 13) and unmutated <i>IGHV</i> (N = 10). <i>(C)</i> CLL B-cells (N = 62) were incubated with 1.5 μM P1446A for 24 hours. Cytogenetics markers were determined by fluorescent in situ hybridization [no marker, 11q, trisomy 12, 13q, 17p]. Horizontal lines represent the mean. <i>(D)</i> PBMCs from patients with CLL (N = 37) or healthy volunteers (N = 6) were incubated with 1.5 μM P1446A or vehicle control for 24 hours. Since we noted a significant variation in baseline apoptosis between patient samples, normalization to the time-matched untreated controls was performed to more clearly reflect the drug-induced apoptosis. *- p<0.05 compared to untreated control.</p

Discovery of a Series of 5,11-Dihydro‑6<i>H</i>‑benzo[<i>e</i>]pyrimido[5,4‑<i>b</i>][1,4]diazepin-6-ones as Selective PI3K-δ/γ Inhibitors

Dual inhibition of PI3K-δ and PI3K-γ is an established therapeutic strategy for treatment of hematological malignancies. Reported molecules targeting PI3K-δ/γ selectively are chemically similar and based upon isoquinolin-1­(2<i>H</i>)-one or quinazolin-4­(3<i>H</i>)-one scaffolds. Here we report a chemically distinct series of potent, selective PI3K-δ/γ inhibitors based on a 5,11-dihydro-6<i>H</i>-benzo­[<i>e</i>]­pyrimido­[5,4-<i>b</i>]­[1,4]­diazepin-6-one scaffold with comparable biochemical potency and cellular effects on PI3K signaling. We envisage these molecules will provide useful leads for development of next-generation PI3K-δ/γ targeting therapeutics

Subtype classification according to BAGS for CLL sample cohorts.

<p>Subtype classification according to BAGS for CLL sample cohorts.</p

Quality assessment of the normal B-cell subsets.

<p><b>a</b>) Unsupervised clustering of surface marker genes in the six normal B-cell subsets. Heat map showing unsupervised hierarchical clustering of normal B-cell subsets based on their expression of the cell surface markers used for FACS. The color scale indicates relative gene expression: brown, low expression; blue, high expression. Color codes: pre-BI, purple; pre-BII, yellow; immature, green; naïve, turquoise; memory, orange; and plasma cells, blue. (<b>b</b>) Principal component analysis of the global gene expression (in total 39,115 genes) in normal B-cell subsets. 1^st, 2^nd, and 3^rd principal components are shown and plotted against each other.</p