Ibrutinib as initial therapy for patients with chronic lymphocytic leukemia

Background: chronic lymphocytic leukemia (CLL) primarily affects older persons who often have coexisting conditions in addition to disease-related immunosuppression and myelosuppression. We conducted an international, open-label, randomized phase 3 trial to compare two oral agents, ibrutinib and chlorambucil, in previously untreated older patients with CLL or small lymphocytic lymphoma. Methods: we randomly assigned 269 previously untreated patients who were 65 years of age or older and had CLL or small lymphocytic lymphoma to receive ibrutinib or chlorambucil. The primary end point was progression-free survival as assessed by an independent review committee. Results: the median age of the patients was 73 years. During a median follow-up period of 18.4 months, ibrutinib resulted in significantly longer progression-free survival than did chlorambucil (median, not reached vs. 18.9 months), with a risk of progression or death that was 84% lower with ibrutinib than that with chlorambucil (hazard ratio, 0.16; P<0.001). Ibrutinib significantly prolonged overall survival; the estimated survival rate at 24 months was 98% with ibrutinib versus 85% with chlorambucil, with a relative risk of death that was 84% lower in the ibrutinib group than in the chlorambucil group (hazard ratio, 0.16; P=0.001). The overall response rate was higher with ibrutinib than with chlorambucil (86% vs. 35%, P<0.001). The rates of sustained increases from baseline values in the hemoglobin and platelet levels were higher with ibrutinib. Adverse events of any grade that occurred in at least 20% of the patients receiving ibrutinib included diarrhea, fatigue, cough, and nausea; adverse events occurring in at least 20% of those receiving chlorambucil included nausea, fatigue, neutropenia, anemia, and vomiting. In the ibrutinib group, four patients had a grade 3 hemorrhage and one had a grade 4 hemorrhage. A total of 87% of the patients in the ibrutinib group are continuing to take ibrutinib. Conclusions: ibrutinib was superior to chlorambucil in previously untreated patients with CLL or small lymphocytic lymphoma, as assessed by progression-free survival, overall survival, response rate, and improvement in hematologic variables. (Funded by Pharmacyclics and others; RESONATE-2 ClinicalTrials.gov number, NCT01722487.)

Positive Feedback between Transcriptional and Kinase Suppression in Nematodes with Extraordinary Longevity and Stress Resistance

Insulin/IGF-1 signaling (IIS) regulates development and metabolism, and modulates aging, of Caenorhabditis elegans. In nematodes, as in mammals, IIS is understood to operate through a kinase-phosphorylation cascade that inactivates the DAF-16/FOXO transcription factor. Situated at the center of this pathway, phosphatidylinositol 3-kinase (PI3K) phosphorylates PIP2 to form PIP3, a phospholipid required for membrane tethering and activation of many signaling molecules. Nonsense mutants of age-1, the nematode gene encoding the class-I catalytic subunit of PI3K, produce only a truncated protein lacking the kinase domain, and yet confer 10-fold greater longevity on second-generation (F2) homozygotes, and comparable gains in stress resistance. Their F1 parents, like weaker age-1 mutants, are far less robust—implying that maternally contributed trace amounts of PI3K activity or of PIP3 block the extreme age-1 phenotypes. We find that F2-mutant adults have <10% of wild-type kinase activity in vitro and <60% of normal phosphoprotein levels in vivo. Inactivation of PI3K not only disrupts PIP3-dependent kinase signaling, but surprisingly also attenuates transcripts of numerous IIS components, even upstream of PI3K, and those of signaling molecules that cross-talk with IIS. The age-1(mg44) nonsense mutation results, in F2 adults, in changes to kinase profiles and to expression levels of multiple transcripts that distinguish this mutant from F1 age-1 homozygotes, a weaker age-1 mutant, or wild-type adults. Most but not all of those changes are reversed by a second mutation to daf-16, implicating both DAF-16/ FOXO–dependent and –independent mechanisms. RNAi, silencing genes that are downregulated in long-lived worms, improves oxidative-stress resistance of wild-type adults. It is therefore plausible that attenuation of those genes in age-1(mg44)-F2 adults contributes to their exceptional survival. IIS in nematodes (and presumably in other species) thus involves transcriptional as well as kinase regulation in a positive-feedback circuit, favoring either survival or reproduction. Hyperlongevity of strong age-1(mg44) mutants may result from their inability to reset this molecular switch to the reproductive mode

Invariant Natural Killer T Cells in Chronic Lymphocytic Leukaemia

Invariant natural killer T (iNKT) cells recognise glycolipid antigens, such as the synthetic ligand alpha galactosylceramide (a-GalCer), in the context of CD1d. Upon recognition of a-GalCer on CD1d, iNKT cells become activated and rapidly produce cytokines. Recruitment of iNKT cells with a-GalCer results in potent antitumour activity in some pre-clinical cancer models. Effector mechanisms include direct cytotoxicity of iNKT cells against CD1d-expressing tumours in the presence of a-GalCer, transactivation of natural killer cells by iNKT cell-derived interferon gamma, and iNKT cell-induced maturation and activation of dendritic cells (DCs), leading to enhanced T cell responses to DC-presented peptides. Chronic lymphocytic leukaemia (CLL) is a clonal malignancy of B lymphocytes. Chemotherapy induces remission in most patients, but most eventually relapse. Allogeneic stem cell transplantation can be curative, but is not available to most patients due to advanced age or co-morbidities. Thus, CLL is an attractive candidate for cancer immunotherapy. This thesis aims to assess the iNKT cell/CD1d axis of patients, and to explore the possibility of exploiting iNKT cells for the immunotherapy of CLL. Peripheral blood mononuclear cells (PBMCs) were isolated from patients with CLL, and from healthy age-matched controls, and analysed by flow cytometry. Absolute number and phenotype of circulating iNKT cells was similar in patients and controls, although patients exhibited a relative reduction in iNKT cells due to expansion of other T cell populations. iNKT cell frequency did not correlate with disease stage or with subsequent progression-free survival in patients with untreated CLL. Expression of CD1d on dendritic cells and monocytes from patients with CLL was similar to controls. The cytokine profile of patient iNKT cells was similar to that of controls. In vitro proliferation of invariant natural killer T (iNKT) cells from patients with CLL was preserved, and iNKT cell lines generated from patients exhibited cytokine and cytotoxicity profiles similar to those from healthy controls, producing both Th1- and Th2-type cytokines, and lysing a target cell in a CD1d- and a-GalCer-dependent manner. Lysis of autologous CLL cells by iNKT cell lines was inefficient. In vitro vaccine recall responses were enhanced by a-GalCer in PBMCs containing high frequencies of iNKT cells. The treatment of leukaemic cells with a-GalCer enhanced their ability to stimulate proliferation of allogeneic PBMCs from healthy donors in vitro, largely due to iNKT cell proliferation. Leukaemic cells treated with a-GalCer induced proliferation of autologous iNKT cells, and a-GalCer treatment also led to enhanced proliferation of ‘conventional’ T cells. These results indicate that the iNKT cell/CD1d axis is largely intact in patients with CLL and suggest that if low iNKT cell frequencies can be overcome, the adjuvant activity of iNKT cells might be exploited in cellular immunotherapy of CLL, for example by employing a-GalCer-pulsed leukaemic cells as a whole tumour vaccine

Invariant Natural Killer T Cells in Chronic Lymphocytic Leukaemia

Invariant natural killer T (iNKT) cells recognise glycolipid antigens, such as the synthetic ligand alpha galactosylceramide (a-GalCer), in the context of CD1d. Upon recognition of a-GalCer on CD1d, iNKT cells become activated and rapidly produce cytokines. Recruitment of iNKT cells with a-GalCer results in potent antitumour activity in some pre-clinical cancer models. Effector mechanisms include direct cytotoxicity of iNKT cells against CD1d-expressing tumours in the presence of a-GalCer, transactivation of natural killer cells by iNKT cell-derived interferon gamma, and iNKT cell-induced maturation and activation of dendritic cells (DCs), leading to enhanced T cell responses to DC-presented peptides. Chronic lymphocytic leukaemia (CLL) is a clonal malignancy of B lymphocytes. Chemotherapy induces remission in most patients, but most eventually relapse. Allogeneic stem cell transplantation can be curative, but is not available to most patients due to advanced age or co-morbidities. Thus, CLL is an attractive candidate for cancer immunotherapy. This thesis aims to assess the iNKT cell/CD1d axis of patients, and to explore the possibility of exploiting iNKT cells for the immunotherapy of CLL. Peripheral blood mononuclear cells (PBMCs) were isolated from patients with CLL, and from healthy age-matched controls, and analysed by flow cytometry. Absolute number and phenotype of circulating iNKT cells was similar in patients and controls, although patients exhibited a relative reduction in iNKT cells due to expansion of other T cell populations. iNKT cell frequency did not correlate with disease stage or with subsequent progression-free survival in patients with untreated CLL. Expression of CD1d on dendritic cells and monocytes from patients with CLL was similar to controls. The cytokine profile of patient iNKT cells was similar to that of controls. In vitro proliferation of invariant natural killer T (iNKT) cells from patients with CLL was preserved, and iNKT cell lines generated from patients exhibited cytokine and cytotoxicity profiles similar to those from healthy controls, producing both Th1- and Th2-type cytokines, and lysing a target cell in a CD1d- and a-GalCer-dependent manner. Lysis of autologous CLL cells by iNKT cell lines was inefficient. In vitro vaccine recall responses were enhanced by a-GalCer in PBMCs containing high frequencies of iNKT cells. The treatment of leukaemic cells with a-GalCer enhanced their ability to stimulate proliferation of allogeneic PBMCs from healthy donors in vitro, largely due to iNKT cell proliferation. Leukaemic cells treated with a-GalCer induced proliferation of autologous iNKT cells, and a-GalCer treatment also led to enhanced proliferation of ‘conventional’ T cells. These results indicate that the iNKT cell/CD1d axis is largely intact in patients with CLL and suggest that if low iNKT cell frequencies can be overcome, the adjuvant activity of iNKT cells might be exploited in cellular immunotherapy of CLL, for example by employing a-GalCer-pulsed leukaemic cells as a whole tumour vaccine

Selecting costimulatory domains for chimeric antigen receptors: functional and clinical considerations

Abstract Costimulatory signals are required to achieve robust chimeric antigen receptor (CAR) T cell expansion, function, persistence and antitumor activity. These can be provided by incorporating intracellular signalling domains from one or more T cell costimulatory molecules, such as CD28 or 4‐1BB, into the CAR. The selection and positioning of costimulatory domains within a CAR construct influence CAR T cell function and fate, and clinical experience of autologous anti‐CD19 CAR T cell therapies suggests that costimulatory domains have differential impacts on CAR T cell kinetics, cytotoxic function and potentially safety profile. The clinical impacts of combining costimulatory domains and of alternative costimulatory domains are not yet clearly established, and may be construct‐ and disease‐specific. The aim of this review is to summarise the function and effect of established and emerging costimulatory domains and their combinations within CAR T cells

Experiences and perspectives on chimeric antigen receptor (CAR) T-cell therapy among recipients, carers and referrers (RE-TELL): a qualitative study to inform CAR T-cell service design

Objectives RE-TELL is a qualitative study, which aims to understand patient, support person, clinician and coordinator experiences and perspectives of chimeric antigen receptor (CAR) T-cell therapy, to inform design of a clinical CAR T-cell service in Aotearoa New Zealand.Design Semistructured qualitative interviews focused on domains of: experience through treatment, elements that work well and those that could be improved on. Interviews used thematic analysis to identify key themes. A workshop was held to obtain participants’ reflections on interim analysis and proposed improvements.Participants New Zealanders with experience of CAR T-cell therapy, including recipients, support persons, clinicians and coordinators.Results We interviewed 19 participants comprising 5 CAR T-cell recipients, 3 support persons, 6 clinicians and 5 coordinators. Four participants identified as Māori. Thematic analysis identified three global themes. The first, ‘sociocultural factors impact CAR T access’, identified potential sources of inequity including geographic, financial and informed consent barriers. The second, ‘varying emotions, roles and enablers’, identified an easier treatment experience compared with alternatives; an underwhelming cell administration process; frustration with inpatient monitoring; burden on support persons and importance of ‘bridge’ organisations such as charities and patient support groups. Lastly, ‘golden opportunities: reimagining CAR T service delivery’, suggested: improved geographical access to CAR T-cell therapy, while retaining consolidated clinician experience; a ‘dashboard’ with information on CAR T-cell treatment, time frames and manufacture; a health navigator to co-ordinate non-medical aspects of treatment and signpost care; embedding of indigenous data sovereignty and ownership of cells; a cell infusion ceremony, incorporating family involvement and Māori cultural elements and outpatient administration and monitoring where possible.Conclusion This study documented the current experience of New Zealanders receiving CAR T-cell therapy and identified opportunities for future service development. These insights are relevant to service design within Aotearoa New Zealand, and other countries developing equitable CAR T-cell services

Non-Invasive Detection of Anaemia Using Digital Photographs of the Conjunctiva

<div><p>Background and Aims</p><p>Anaemia is a major health burden worldwide. Although the finding of conjunctival pallor on clinical examination is associated with anaemia, inter-observer variability is high, and definitive diagnosis of anaemia requires a blood sample. We aimed to detect anaemia by quantifying conjunctival pallor using digital photographs taken with a consumer camera and a popular smartphone. Our goal was to develop a non-invasive screening test for anaemia.</p><p>Patients and Methods</p><p>The conjunctivae of haemato-oncology in- and outpatients were photographed in ambient lighting using a digital camera (Panasonic DMC-LX5), and the internal rear-facing camera of a smartphone (Apple iPhone 5S) alongside an in-frame calibration card. Following image calibration, conjunctival erythema index (EI) was calculated and correlated with laboratory-measured haemoglobin concentration. Three clinicians independently evaluated each image for conjunctival pallor.</p><p>Results</p><p>Conjunctival EI was reproducible between images (average coefficient of variation 2.96%). EI of the palpebral conjunctiva correlated more strongly with haemoglobin concentration than that of the forniceal conjunctiva. Using the compact camera, palpebral conjunctival EI had a sensitivity of 93% and 57% and specificity of 78% and 83% for detection of anaemia (haemoglobin < 110 g/L) in training and internal validation sets, respectively. Similar results were found using the iPhone camera, though the EI cut-off value differed. Conjunctival EI analysis compared favourably with clinician assessment, with a higher positive likelihood ratio for prediction of anaemia.</p><p>Conclusions</p><p>Erythema index of the palpebral conjunctiva calculated from images taken with a compact camera or mobile phone correlates with haemoglobin and compares favourably to clinician assessment for prediction of anaemia. If confirmed in further series, this technique may be useful for the non-invasive screening for anaemia.</p></div