GENETICS OF CHRONIC LYMPHOCYTIC LEUKEMIA AND LYMPHOPLASMACYTIC LYMPHOMA

BCR pathway inhibition as therapy for chronic lymphocytic

leukemia and lymphoplasmacytic lymphoma
Adrian Wiestner1
1Hematology

Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD

Chronic lymphocytic leukemia (CLL) and lymphoplasmacytic lymphoma (LPL) are malignancies of mature B cells. In
LPL, mutations of the adaptor protein MYD88 (L265P) in the Toll-like receptor pathway have been recognized recently
as being a hallmark of the disease and indicate a dependence of the tumor on this pathway. In CLL, functional studies
have implicated BCR activation in the tissue microenvironment as a pivotal pathway in the pathogenesis. Brutons
tyrosine kinase (BTK) and the PI3K isoform are essential for BCR signaling and also seem to be required for signal
transduction in LPL cells, even if the role of BCR signaling in this disease remains less well defined. Ibrutinib, a covalent
inhibitor of BTK approved by the Food and Drug Administration as a second-line treatment for CLL, and idelalisib, a
selective inhibitor of PI3K, achieve excellent clinical responses in both diseases irrespective of classic markers
indicating high-risk disease. Several additional inhibitors targeting BTK and PI3K, as well as the spleen tyrosine
kinase, have entered clinical trials. This review discusses the biologic basis for kinase inhibitors as targeted therapy for
CLL and LPL and summarizes the clinical experience with these agents.

Learning Objectives

Gain an overview of the role of BCR signaling in the

pathogenesis and treatment of CLL and LPL
Be able to identify kinases that can be targeted therapeutically
in CLL and LPL
Understand differences in clinical response and side effect
profiles between kinase inhibitors and standard chemoimmunotherapy
Be able to discuss the pros and cons of targeted treatment with
kinase inhibitors

Introduction
Chronic lymphocytic leukemia (CLL) is characterized by the
accumulation of mature monoclonal B cells in the blood, bone
marrow (BM), lymph nodes, and spleen. The diagnosis of CLL
requires the presence of 5000 tumor cells/L of blood with a
characteristic immunophenotype (CD19, CD5, CD23, weak
CD20 expression).1 Small lymphocytic lymphoma (SLL) shares the
biological characteristics of CLL, but is distinguished by having
5000 tumor cells/L of blood in the presence of pathologic
lymphadenopathy, splenomegaly, or BM disease. The standard of
care for CLL is watchful waiting of asymptomatic patients;
treatment is reserved for patients having symptomatic disease or
compromised BM function.2 This approach is guided by the absence
of curative treatments (with the exception of allogeneic stem cell
transplantation), clinical trials showing no benefit for early treatment in asymptomatic patients, and the relatively long and heterogeneous natural history of the disease. Although the median survival
of all patients in a large referral center was 11 years,3 it can be much
shorter for patients in high-risk disease groups; on the other hand,
patients with indolent CLL can have a life expectancy comparable
to age-matched controls.4,5
The combination of chemotherapy with anti-CD20 monoclonal
antibody (mAb), referred to as chemoimmunotherapy, was shown to
be superior to chemotherapy alone and has become the standard

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first-line treatment for CLL.6-8 However, the majority of patients

will relapse within years of first treatment. Median progression-free
survival (PFS) after first-line chemoimmunotherapy can be 2
years in patients with adverse cytogenetic markers, in particular in
those with deletion of chromosome 17p (del17p) or in those
carrying somatic mutations in TP53, NOTCH1, or SF3B1.9 Clonal
evolution and the selective pressure exerted by treatment can
promote the outgrowth of cells carrying additional genetic lesions
that confer treatment resistance. For example, del17p is present in
10% of patients at the time of first-line therapy, but in up to 1/3 of
patients with relapsed disease. Identifying treatment options for
patients with relapsed/refractory disease and for those with del17p
has been and remains a major need.
Lymphoplasmacytic lymphoma (LPL) is a malignancy of mature B
cells residing in BM and lymph nodes that secrete immunoglobulin,
mostly of the IgM type.10 Accumulation of large amounts of clonal
IgM, referred to as Waldenstroms macroglobulinemia, can lead to
hyperviscosity syndrome and neuropathy. Other common disease
manifestations include cytopenias and constitutional symptoms. In
many regards, LPL is an intermediary between CLL and multiple
myeloma and treatment often consists of drugs used in either of the
other diseases, including nucleoside analogs, anti-CD20 mAb, and
proteasome inhibitors.10
The BCR is a master regulator of B cells that promotes their
development, survival, proliferation, functional differentiation, and
migration. Expression of a functional BCR is required for the
survival of all B cells past the earliest development stages. PI3K,
spleen tyrosine kinases (SYK), and Brutons tyrosine kinase (BTK)
are essential for BCR signal transduction, and their knockout in
mouse models leads to impaired antigen-driven maturation and
expansion of B cells. Over the years, an increasing number of B-cell
malignancies were recognized to depend on BCR signaling for
proliferation and/or survival.11,12 This concept, although in many
cases shown or at least supported by genetic and biologic studies, is
emphasized by the clinical success of kinase inhibitors that block

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Figure 1. BCR signaling and downstream pathways. The BCR consists of a surface transmembrane Ig receptor associated with the Ig alpha (Ig,
CD79A) and Ig beta (Ig, CD79B) chains. BCR signaling in response to antigen binding induces LYN- and SYK-dependent phosphorylation of tyrosine
motifs (phosphorylation denoted by P in yellow circle) on CD79A and CD79B. Several protein tyrosine kinases (red symbols) and the lipid kinase
PI3K (green symbol) transmit survival and proliferation signals and regulate cell maturation and migration. Small-molecule inhibitors of select kinases in
the BCR pathway that have demonstrated significant clinical activitgips2 indAR ed.

BCR signaling in a variety of B-cell malignancies. Here, I briefly

review the BCR signaling pathway and its role in CLL, summarize
the clinical experience with these targeted agents, and provide an
outlook on their possible future role in the therapeutic approach to
CLL and LPL.

BCR and Toll-like receptor (TLR) signaling in CLL

and LPL

Genetic evidence for a role of antigen selection

A role for antigen signaling in the pathogenesis of CLL is indicated
by observations that many CLL cells use a restricted repertoire of
immunoglobulin heavy chain variable (IGHV) region genes, which
encode the antigen-binding domains of the BCR.13,14 Naive B cells
acquire these IGHV mutations after antigen biding as part of a
regulated maturation process in the germinal center of the lymph
node. The presence or absence of somatic mutations in the clonal
IGHV gene distinguishes 2 major CLL subtypes; IGHV mutated
(M-CLL) and IGHV unmutated (U-CLL, which has 98% sequence homology to the germline IGHV).1 M-CLL cells appear to
be anergic, that is, in a state of hyporesponsiveness to BCR
activation that can result from frequent BCR stimulation.15 In
contrast, many U-CLL clones have BCR structures found in
polyreactive B cells that weakly bind many different antigens.16,17
Specific antigens may include microbial structures, molecules
expressed on dying cells, or classic autoantigens.18 In addition, it
was shown that the BCR of many CLL cells recognizes an epitope
that is part of the CLL BCR itself, possibly contributing to
autostimulation on a single-cell level.19 The observation that U-CLL
is a more rapidly progressive disease with inferior survival compared with M-CLL indicates that the degree of BCR activation
and/or the type of antigen may be important. LPL cells derive from a
postgerminal center B cell and typically express mutated IGHV
genes.

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BCR signaling in CLL

Comparative analysis of CLL cells isolated from the blood and
lymph nodes provided direct evidence for ongoing antigendependent signaling through the BCR in vivo and suggested that
the lymph node may be the primary site of BCR activation.20
Therefore, active antigenic signaling continues throughout the
disease course of CLL. This conclusion is also supported by the
observations of a reversible down-modulation of surface IgM
expression on CLL cells and the anergic state of some CLL
cells.15,21 BCR signaling is likely a key driver of CLL proliferation; in vitro BCR activation supports CLL cell survival and
proliferation22-26 and a strong cellular response to BCR activation
correlates with a more aggressive disease course.20,27,28 Consistent with these in vitro data, the degree of BCR activation in CLL
cells in vivo correlates with increased tumor proliferation and
shorter time to progression.20
The transduction of signals from the BCR involves a network of
kinases and adaptor molecules that connect antigen stimulation to
intracellular responses (Figure 1).29 In vivo, additional elements
present in the tissue microenvironment cooperate with the BCR and
may influence the cellular response. The term microenvironment
collectively describes cellular, structural, and soluble components
of the anatomic compartment in which the CLL cells reside.30 In
vitro, different types of stromal cells and monocyte-derived cells,
designated nurse-like-cells, promote CLL cell survival.30-32 In
addition, T cells aggregate with proliferating CLL cells in so-called
proliferation centers in BM and lymphoid tissue and are required for
CLL cell proliferation in mice engrafted with PBMCs from CLL
patients.33 Extensive in vitro studies identified many pathways and
factors that enhance CLL cell survival and promote limited proliferation, including TLRs, cytokines, chemokines, CD40, B-cellactivating factor of tumor necrosis factor family (BAFF), integrins,
and components of the extracellular matrix.22,25,31,34-38 Many of
these extrinsic factors signal through SYK, PI3K, and BTK and

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Table 1. Select inhibitors of kinases in the BCR pathway in clinical trials

Target
SYK

Drug, company
Fostamatinib

(R788),83

Rigel

GS-9973,90,91 Gilead
BTK

Ibrutinib (PCI-32765),53,64 Pharmacyclics

CC-292 (AVL-292),103 Celgene

ONO-4059,104 Ono Pharma

PI3K

ACP-196, Acerta Pharma

Idelalisib (GS-1101, CAL-101),52,63 Gilead

IPI-145,105 Infinity
AMG-319,106 Amgen

Notes
Oral prodrug of R406, an inhibitor of SYK and several other kinases. Common adverse
effects: fatigue, diarrhea, hypertension, cytopenias. CLL: ORR 55%
Highly selective for SYK; common AEs in phase 2: fatigue, diarrhea, transaminase
elevations.
First FDA-approved BTK inhibitor for second-line treatment of CLL and MCL.
Covalent binding to Cys481 leads to irreversible inhibition. Once-daily oral dosing.
ORR 71% in relapsed/refractory CLL patients, additional 18% with PRL. Estimated
PFS at 26 months, 75%.
Covalent binding to Cys481 leads to irreversible inhibition. ORR with twice-daily
dosing better than once daily.
Covalent binding to Cys481 leads to irreversible inhibition. Orally once a day,
preliminary ORR in relapsed/refractory CLL comparable to ibrutinib.
Covalent binding to Cys481 leads to irreversible inhibition. Phase 1 study initiated.
Selective inhibitor of PI3K. Twice-daily oral dosing. Single-agent ORR in
relapsed/refractory CLL patients, 39% plus 33% PRL; in SLL, 61%; in LPL, 80%.
In combination with rituximab, ORR 81% and PFS at 6 months 93%.
Selective inhibitor of PI3K and PI3K. Twice-daily oral dosing. MTD at 75 mg twice
daily. ORR in relapsed/refractory CLL, 52%.
Selective inhibitor of PI3K. Once-daily oral dosing.

ORRs given here are by IWCLL 2008 criteria.

For ongoing studies, please see www.clinicaltrials.gov.

activate similar intracellular pathways, most prominently the PI3K/

AKT/mTOR, NF-B, and MAPK pathways. It is therefore difficult
to estimate to what degree any single factor or pathway may be
necessary or sufficient for CLL pathogenesis.39 Many of the most
powerful adverse prognostic markers in CLL relate to both BCR
signaling and the ability of the tumor cells to interact with the
microenvironment, including unmutated IGHV, expression of
ZAP70, and CD49d.40 In addition, CCL3 and CCL4 serum levels,
which may serve as biomarkers of BCR signaling strength, also
confer prognostic information.41

MYD88 mutations and TLR signaling in LPL

Somatic mutations in MYD88 (L265P) are found in 90% of
patients with WM and are also common in IgM monoclonal
gammopathy of undetermined significance, suggesting that this
mutation may play a role in the development of the disease.42,43
MYD88 is an adaptor in the TLR pathway and the L265P mutation
may enhance or trigger signaling through BTK and PI3K to the
NF-B and AKT/mTOR pathways.10,44 A more detailed discussion
of the genetics of LPL is provided in the chapter by Dr. Davide
Rossi in this publication.

Small-molecule inhibitors of BCR signaling

Several kinases in the BCR pathway can be targeted by small
molecules. Most advanced in their clinical development are inhibitors of BTK, PI3K, and SYK (Table 1). Many of these inhibitors
were initially developed for use in inflammatory diseases. Preclinical in vitro and in vivo studies identified these kinases as promising
targets for the treatment of CLL and other B-cell malignancies
(reviewed previously39), and their inhibition effectively interrupts
BCR signaling, leading to reduced activation and proliferation of
tumor cells.45-48 Because the same kinases also play important roles
in pathways that regulate tumor-microenvironment interactions, the
inhibitory effects of the small molecules extend beyond BCR
signaling to such microenvironmental factors as chemokines, CD40
ligand, BAFF, fibronectin, and TLR ligands.48-50 Likewise, most
inhibitors are not entirely specific to only one kinase, but may also
inhibit additional (related) kinases to some degree.18,39 Furthermore,

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the kinases targeted by these small molecules also function in other

immune cells. To what degree such tumor-extrinsic effects contribute to efficacy or to adverse events are becoming an important area
of investigation.51
Patients treated with kinase inhibitors typically experience symptomatic improvement and rapid reduction in lymphadenopathy in
parallel with a transient increase in absolute lymphocyte count
(ALC; Table 2).52-54 In fact, in CLL, this treatment-induced
lymphocytosis is a class effect of kinase inhibitors that target BCR
signaling,39 with the caveat that it may be missed because the peak
ALC can occur within the first days or even hours of starting the
drug.54 There is consensus among experts that this treatmentinduced lymphocytosis in the absence of signs of progression in
other disease sites does not indicate disease progression and that
patients can and should be maintained on drug.55 In addition, there is
currently no evidence that the drug-induced increase in lymphocytosis in CLL patients is associated with morbidity.52-54 In most
patients, the treatment-induced lymphocytosis peaks within the first
2 months before gradually resolving, but there is considerable
interpatient variability. A subset of patients may show persistent
lymphocytosis for many months to years on monotherapy and this
does not appear to be a harbinger of treatment failure.47 Treatmentinduced lymphocytosis is not limited to CLL; a 3-fold or greater
increase in ALC was also recorded in patients with indolent
non-Hodgkins lymphoma (NHL) treated with idelalisib, mostly in
SLL (64% of patients), and less commonly in follicular lymphoma
(18%). Treatment-induced lymphocytosis was not seen in patients
with LPL.56 In mantle cell lymphoma (MCL), ibrutinib transiently
increased the ALC (50% increase and 5000 cells/L) in 34% of
patients.57
Decreased cell adhesion and reduced homing and migration of CLL
cells are the likely factors contributing to lymphocytosis in patients
treated with kinase inhibitors.58-60 Changes in immunophenotypic
markers indicate that the increase in circulating CLL cells, at least in
the first days, is due to the egress of cells from tissue compartments
into the peripheral blood.54 Clearly, this lymphocytosis is not due to

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Table 2. Characteristic clinical observations in CLL patients treated

with kinase inhibitors
Treatment-induced lymphocytosis
Increase in ALC seen in most patients; peaks days to weeks from
starting drug; resolution can take many months; pronounced
interpatient variability.
Class effect; does not indicate progressive disease in absence of
other signs of progression; asymptomatic.
Due to redistribution of cells out of the lymph node (tissues) into the
blood.
Typically decreases when stopping drug.
Persistent lymphocytosis does not predict inferior outcome.
Adverse events on kinase inhibitors:
Mostly well tolerated oral agents and limited myelosuppression.
Common adverse events: fatigue, diarrhea, infections.
Rate of infection higher in relapsed/refractory patients, appears to be
due to underlying disease.
Ibrutinib: frequent grade 1 ecchymosis, rare grade 3 bleeding (avoid
Coumadin, hold drug for invasive procedures).
Idelalisib: grade 3 diarrhea, colitis, and pneumonitis.
Treatment response and efficacy:
High single-agent ORR also in high risk disease and in patients with
del17p; few CRs.
Typically rapid improvement in cytopenias and disease symptoms.
Rapid reduction in lymphadenopathy, especially over the first 2
months.
Continuous but slower rate of improvement in response on extended
therapy.
Durable responses despite the presence of residual disease.
Inhibition of BCR signaling paralleled by decreased tumor
proliferation.
Revision of response criteria: PRL denotes a PR with persistent
lymphocytosis.

clonal expansion, because several studies have reported reduced

tumor proliferation within days of starting treatment.45,47,54 Importantly, these targeted agents do not just redistribute the disease,
because the increase in ALC does not match the decrease in nodal
disease and there is often a dramatic and rapid reduction in total
tumor burden, especially within the first few months.54 We also
found that, upon starting ibrutinib, the frequency of dead or dying
cells in the circulation doubled from baseline. Accordingly, ibrutinib inhibits proliferation and increases the rate of cell death,
resulting in a gradual attrition of the tumor burden over time that
matches well with the observed clinical response.54 The same
conclusion has been reached using mathematical modeling.61 Therefore, despite significant reductions in total tumor burden over just a
few weeks, tumor lysis syndrome has not been a common concern.62-64
Because of the treatment-induced lymphocytosis, many patients do
not meet response criteria defined in the 2008 International Workshop on Chronic Lymphocytic Leukemia (IWCLL) guidelines
despite clear and substantial clinical benefit.52,53,64 Recently, the
authors of the IWCLL guidelines have clarified that patients
meeting criteria for partial response (PR) but who have persistent
lymphocytosis may be considered responders.65
In the next sections, I discuss in more detail ibrutinib, which was
approved by the Food and Drug Administration (FDA) in February
2014 as a second-line treatment for CLL, and idelalisib, on which a
decision is expected by August 2014. This is followed by a brief
discussion of other kinase inhibitors in clinical trials.

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Ibrutinib
Ibrutinib (formerly PCI-32765) is an orally bioavailable BTK
inhibitor that irreversibly inactivates the kinase by covalently
binding to a cysteine residue (Cys481) near the active site.66,67 BTK
is a cytoplasmic tyrosine kinase of the TEC family that is essential
for BCR signaling and couples BCR-induced calcium release to
activation of the NF-B pathway and cellular proliferation.68
Loss-of-function mutations in BTK block B-cell maturation at the
pre-B-cell stage and cause X-linked agammaglobulinemia (also
known as Brutons agammaglobulinemia), which is characterized
by the virtual absence of mature B cells and immunoglobulins,
resulting in recurrent bacterial infections.69 Although BTK is
expressed in myeloid cells, it does not appear to have essential
functions outside of the B-cell compartment.68
Ibrutinib was approved by the FDA in November 2013 for the
treatment of relapsed MCL and in February 2014 for relapsed/
refractory CLL. BCR activation in B cells is inhibited with an IC50
of 10 nM.66,67 Few other kinases have homologous cysteine
residues that can be covalently bound by ibrutinib, thereby conferring selective target inhibition.70 However, one of the other kinases
inhibited by ibrutinib is ITK, the inhibition of which has been shown
to enhance Th1-type immune responses in murine models.51 Nevertheless, BTK is likely the key target, as indicated by genetic mouse
models and emerging data on ibrutinb resistance (discussed below).
Due to its covalent binding to BTK, ibrutinib can be given once
daily despite the short half-life of the drug. The phase 1 study that
dosed ibrutinib up to 12.5 mg/kg once daily did not establish a
maximum tolerated dose.71 Target site occupancy in BTK was
measured using a fluorescently labeled derivative of ibrutinib. Full
BTK occupancy, a surrogate of complete kinase inhibition, was
observed at 4 hours after administration of doses of 2.5 mg/kg.
Subsequent studies in CLL used fixed doses of 420 and 840 mg once
daily.53 On day 8, the pre-dose occupancy of BTK at the 420 mg
dose level ranged from 60% to 99%, with no correlation between
the degree of inhibition and best objective response.53

Safety. Ibrutinib was very well tolerated and treatment discontinuation because of side effects rare. The most common side effects
were grade 1-2, including diarrhea (47% of patients), upper
respiratory tract infections (33%), fatigue (28%), cough (31%),
arthralgia (27%), rash (27%), pyrexia (22%), and peripheral edema
(21%).53 Grade 3 or 4 anemia, neutropenia, or thrombocytopenia
were seen in 15% of patients. Bleeding events grade 3 occurred
in 4 patients.53 Although BTK may play a role in glycoprotein
signaling in platelets, the clinical significance of BTK inhibition is
not clear and no consistent effect of ibrutinib on platelet aggregation
was seen in routine testing.72 Grade 3 pneumonia and bacteremia
was seen in 12% and 5% of patients with relapsed/refractory
disease, respectively.53 However, this likely reflects the infection
risk in this high-risk patient population because the frequency of
infections decreased with time on study from 7.1 events per 100
patient-months during the first 6 months to 2.6 per 100 patientmonths thereafter. In addition, grade 3 infections were less
common in elderly, previously untreated patients.64 The majority of
adverse events resolved without the need for suspension of treatment. Interestingly, ibrutinib did not significantly reduce immunoglobulin levels; on the contrary, both IgA and IgM have been found
to increase on treatment.53,71,73
Single-agent efficacy. The overall response rate (ORR) in the

American Society of Hematology

phase 1 study in patients with relapsed/refractory B-cell malignancies overall was 60%, with the highest rates in CLL (79%), MCL
(78%), and LPL (75%). In this dose escalation trial, 1/3 of patients
were treated at doses below the dose chosen for phase 2 studies.
However, responses occurred at all dose levels.71
In the phase 1b/2 study in relapsed/refractory CLL, the ORR was
71% by 2008 IWCLL criteria,2 with complete response (CR) in 2
patients, and an additional 18% of patients achieved a PR with
lymphocytosis (PRL). ORR was comparable across different risk
groups, including del17p. At 26 months, the estimated PFS and
overall survival (OS) were 75% and 83%, respectively. Disease
progression occurred in 11 patients and, in 7, this appeared as a
biologic transformation to diffuse large B-cell lymphoma (Richters
transformation). For patients with del17p (n 28), the estimated
rates of PFS and OS at 26 months were 57% and 70%, respectively.53 In our investigator-initiated, single-center, phase 2 trial
(NCT01500733), PR at 6 months was recorded in 81% of patients
with no del17p and in 53% of patients with del17p. However,
including PRL, the ORR was 91% and 96%, respectively. The
estimated event-free survival at 14 months was 93%.74
In an open label phase 3 study, 391 patients with relapsed or
refractory CLL or SLL were randomly assigned to receive daily
ibrutinib or the anti-CD20 mAb ofatumumab.62 The ORR for
ibrutinib was 42.6% and for ofatumumab it was 4.1%. An additional
20% of ibrutinib-treated patients had PRL. At 6 months, the PFS
with ibrutinib was 88% compared with 65% with ofatumumab
(P .001). Ibrutinib also significantly improved OS at 12 months
to 90% compared with 81% in the ofatumumab arm.

Combination efficacy. Burger at al reported on ibrutinib in

combination with rituximab for 6 cycles, followed by ibrutinib until
disease progression.75 The ORR was 95%, with CR in 8%. The
redistribution lymphocytosis peaked earlier and resolved more
rapidly than with single-agent ibrutinib. Brown et al reported results
of a phase 1b/2 trial of 33 relapsed/refractory CLL patients (50%
refractory to purine analogs, 53% bulky disease, 23% del17p)
treated with ibrutinib in combination with bendamustine and
rituximab.76 The ORR was 93% (13% CR) and at a median
follow-up of 8.1 months the PFS was 90%. The response was
compared with a historical ORR of 59% with bendamustine and
rituximab alone.

Idelalisib
Idelalisib (formerly GS-1101 and CAL-101) is an orally bioavailable, selective, reversible inhibitor of the PI3K isoform. The PI3K
pathway is a key hub linking many signaling pathways to cellular
growth, proliferation, and survival.77,78 PI3K isoforms and are
expressed ubiquitously, whereas the PI3K isoform is primarily
expressed in leukocytes. PI3K is essential for antigen-induced
BCR signaling. In addition, PI3K can also participate in BCR
signaling and promote cell survival (reviewed previously39). In a
dose escalation phase 1 study of oral idelalisib in indolent NHL,56
MCL80 and CLL52 patients were treated at 6 dose levels ranging
from 50 to 350 mg once or twice daily, and remained on continuous
therapy while deriving clinical benefit. No maximum tolerated dose
was established. Based on consistent reductions in lymphadenopathy, long PFS, and pharmacokinetic considerations, a dose of 150
mg twice daily was chosen for future studies.56

Safety. The phase 1 dose escalation study conducted across a wide

range of hematologic malignancies enrolled 54 patients with

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relapsed/refractory CLL.52 Commonly observed grade 3 adverse

events were pneumonia (20%), neutropenic fever (11%), and
diarrhea (6%).52 Most pneumonias appeared to be bacterial and 2
patients developed Pneumocystis jiroveci pneumonia. The rate
of pneumonia on idelalisib was comparable to the rate of 0.06
pneumonias/patient-month reported previously for a similar CLL
population.52,81 Two cases of possibly drug-related organizing pneumonia and one case of interstitial pneumonitis responded to corticosteroids
and 2 of the 3 patients continued idelalisib. Treatment-emergent grade
3 neutropenia (43%), anemia (11%), and thrombocytopenia (17%)
were reported mostly in patients with preexisting cytopenias.52 Diarrhea was reported in 29.6% of patients (grade 3 in 5.6%) and colitis in
7.4%. Except for 1 case, transaminase elevations in 28% of CLL
patients were grade 3.
On a phase 2 study, 125 patients with indolent NHL were treated
with idelalisib 150 mg twice daily, until disease progression.83
Twenty percent of patients discontinued drug due to adverse events
and 34% required a dose reduction. Grade 3 diarrhea, colitis, or
both developed in 16% of patients. Transaminase elevations were
more common in indolent NHL than in CLL and were grade 3 in
13% of patients.82 The transaminase elevations were not dose
related and appeared to be idiosyncratic reactions.56

Single-agent efficacy. Among CLL patients, the ORR according

to the 2008 IWCLL criteria was 39%.52 An additional 33% of
patients had PRL. The median time to response was 1 month. The
median PFS for all CLL patients enrolled was 15.8 months and 32
months for those receiving continuous dosing with idelalisib 150
mg twice daily. Although patients with a del17p or TP53 mutation
responded to treatment, the median PFS in these patients was only 5
months, compared with 41 months in patients without this abnormality.52 The ORR in patients with LPL was 80%.82

Combination efficacy. Study 116 randomized 220 frail patients

with relapsed CLL to either idelalisib with rituximab or rituximab
with placebo.63 The data-safety-monitoring board recommended
early stopping due to excess events in the placebo group. The ORR
(all PRs) was 81% in the idelalisib group compared with 13% in the
placebo group. At 24 weeks, the PFS was 93% in the idelalisib
group and 46% in the placebo group. The benefit of idelalisib and
rituximab was similar in groups stratified by status of del17p, TP53
mutation, and IGHV mutation. Consistent with the monotherapy
experience, serious adverse events more often encountered with
idelalisib were pneumonitis and diarrhea. In contrast, infusion
reactions with rituximab appeared to be milder in the idelalisib
group.63

Select additional kinase inhibitors in clinical trials

In the slightly more than 7 years since the first patient was treated
with the SYK inhibitor fostamatinib,83 there has been a virtual
explosion of small molecules that target kinases in the BCR
pathway (reviewed previously39,84). In addition to ibrutinib, 3 other
covalent BTK inhibitors have entered clinical trials (CC-292,
ONO-4059, and ACP-196). In addition, several noncovalent BTK
inhibitors are in preclinical or very early clinical development
(reviewed previously84). Many different PI3K inhibitors are in
clinical trials. In B-cell malignancies, the focus has been on PI3K
inhibitors including idelalisib, AMG-199, and IPI-145 (which also
inhibits PI3K). Isoform-selective targeting of the PI3K pathway is
an attractive option to prevent adverse events seen with inhibitors
targeting multiple PI3K isoforms. However, in transformed cells,
the dominant role of a specific isoform may be lost and different

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isoforms can assume redundant functions.85 Whether this will give

rise to treatment failure remains to be defined. Table 2 lists select
inhibitors in clinical trials; some of these are discussed briefly
below.

SYK inhibitors
SYK and ZAP70 are cytoplasmic tyrosine kinases that together
form a unique family and are each essential for BCR and TCR
signaling transduction, respectively. In CLL, ZAP70 expression is
more common in U-CLL than M-CLL, correlates with a more
progressive disease course, and enhances the cellular response to
BCR activation and chemokines independently of its kinase activity.28,86 Upon antigen binding to the BCR, LYN phosphorylates
SYK, which in turn amplifies the initial BCR signal and activates
the downstream signaling cascade. In addition, SYK is involved in
chemokine, integrin, and Fc-receptor signaling.87
The first clinical trial of a SYK inhibitor used fostamatinib in
patients with relapsed/refractory NHL and CLL.83 The doselimiting toxicity was a combination of diarrhea, neutropenia, and
thrombocytopenia. The ORR in 11 patients with CLL was 55%. In
tumor cells sampled on treatment, fostamatinib effectively inhibited
BCR signaling and reduced tumor proliferation.88 The subsequent
development of fostamatinib focused on rheumatoid arthritis, with
mixed results.89 GS-9973 is a highly selective and orally efficacious
SYK inhibitor.90 On a phase 2 study, patients with CLL or indolent
NHL were treated at 800 mg twice daily. Grade 3 adverse events
were fatigue, transaminase elevations, and nausea. Nodal responses
were seen in patients with or without del17p.91

Considerations and outlook on the role of kinase

inhibitors in CLL
Why do kinase inhibitors work (so well)?
The impressive clinical activity of multiple different kinase inhibitors seems to be better than one would have predicted. Whether all
of the therapeutic effects can be attributed to the inhibition of BCR
signaling is not clear and the answer may differ among different
B-cell malignancies. Functional studies with CLL cells in vitro,
ongoing activation of CLL cells through the BCR in vivo, and
evidence for antigen selection in cases with stereotyped BCRs are
strong indicators that the BCR is a pivotal pathway in pathogenesis
and disease progression (reviewed previously11,18,29,39,92). However,
BCR activation seems to occur primarily in the lymph node
microenvironment, where multiple additional factors may contribute or even be required for tumor proliferation.18,39,93 T cells may
have an essential role, as shown by experiments demonstrating that
reconstitution of a humanized microenvironment that can support
CLL cell proliferation in NSG mice requires the cotransfer of
human T cells.33,94 When T cells are eliminated, CLL cells do not
proliferate.
In LPL, some observations also indicate a possible role for BCR
activation. However, the MYD88 L265P mutation in the TLR
pathway contributes to BTK activation, and both ibrutinib and
idealisib may be clinically effective because they disrupt the
aberrant TLR signaling in these tumors.43,95 It is possible that these
kinase inhibitors are only efficacious because SYK, BTK, and
PI3K contribute to many different pathways with important roles
in B-cell biology.39 However, this view begs the question of how
inhibition of such central hubs that are active not only in B cells,
but also in other lymphocytes and myeloid cells, can be as safe as
these drugs appear to be.

130

What are the implications of residual disease on treatment

with kinase inhibitors?
Most responses to monotherapy with kinase inhibitors are PRs and,
even in combination with anti-CD20 mAbs, deep remissions are
infrequent.63,75 Nevertheless, many responses are maintained for
long periods of time despite the presence of residual disease.47,53
Although the depth of response often increases on continued
treatment, there is a subset of patients who still have lymphocytosis
at 12 or even 24 months.47,53 These persistent tumor cells are
quiescent or dormant in that the activity of key signaling
pathways is down-regulated, markers of cell activation are reduced,
and tumor proliferation is undetectable.46,47 Therefore, these cells
should not be considered resistant to drug and are not a harbinger of
imminent relapse. An important landmark analysis showed that
CLL patients who had PRL at the end of the first year on ibrutinib
continued to maintain their response, whereas some patients having
achieved a traditional PR or even CR relapsed over the next 12
months.47

What are the effects of kinase inhibitors on the normal

immune system?
Inhibitors of the kinases SYK, BTK, and PI3K can affect normal
immune function in 2 ways. First, the targeted kinase also functions
in cells other than B cells. For example, PI3K promotes the
maturation and expansion of CD4 T-cell subsets and of T-regulatory
cells.78 Second, the kinase inhibitor is not specific for only one
kinase. For example, ibrutinib can covalently bind and thereby
irreversibly inactivate a limited number of other kinases.66,70 One
such kinase is ITK in T cells. Dubrovsky et al showed that ITK is
inhibited in T cells of CLL patients treated with ibrutinib and, in a
mouse model, they demonstrated that ibrutinib enhanced a Th1-type
immune response that allowed the mice to better clear parasitic or
intracellular bacterial infections.51 Further, in natural killer cells and
macrophages, ibrutinib can inhibit Fc-receptor signaling, probably
through combined effects on BTK, ITK, and TEC. A practical
consequence may be that inhibition of these kinases could interfere
with effector mechanisms contributing to the clinical efficacy of
therapeutic antibodies.96 Whether these effects on other cell types
are relevant for treatment responses in B-cell malignancies and/or
for the side effect profile of different small molecules will be
important to define. In the case of ibrutinib, inhibition of BTK
appears to be the mainstay of therapeutic activity, as suggested by
the selection of BTK mutations in resistant disease and mouse
models of CLL that, when crossed with BTK-knockout mice, have
substantially delayed disease onset.97,98

Resistance to kinase inhibitors

Resistance mechanisms to kinase inhibitors are being identified.
Interestingly, they are not the usual suspects. Patients with adverse
cytogenetic features, including those with del17p and del11q, bulky
disease, or unmutated IGHV respond, at least initially, as well as
patients without these characteristics.53,63 Mechanisms of resistance
likely will differ depending on which kinase is targeted. Recently,
acquired mutations in BTK and in phospholipase C gamma 2
(PLC2), a direct downstream target of BTK, were identified in 6
CLL patients who developed resistance to ibrutinib.99,100 Five
patients showed a cysteine-to-serine mutation in BTK (C481S) at
the binding site of ibrutinib that disrupts the covalent binding
between the drug and the kinase and thereby dramatically decreases
the potency of ibrutinib. Two patients, including one with a C481S
mutation, had gain-of-function mutations in PLC2 that led to
autonomous BCR signaling.99 In addition, patients with Richters

American Society of Hematology

transformation appear not to (durably) respond to ibrutinib,53

suggesting that some of the biologic changes occurring during
transformation lead to BTK independent tumors. Although any
resistance is a clinical disappointment, the frequency so far is quite
low, and the specific mutations in BTK are a powerful validation of
the target and its importance in tumor biology. In MCL, high
expression of PI3K has been associated with resistance to idelalisib.79 Whether PI3K could play a similar role in CLL is not clear.

Is combination therapy the way to go?

The absence of deep remissions, possible resistance to monotherapy, and the unproven tolerability and high cost of chronic
treatment with these novel agents are all good reasons to pursue
combination therapy. Current data on combinations in relapsed/
refractory CLL patients are limited and response rates are not that
different from monotherapy. In general, there is more rapid control
of the treatment-induced lymphocytosis. Whether this is a valid goal
to justify the possible toxicity of the additional agent is not evident.
In particular, the more important end points such as PFS and rate of
resistance await longer follow-up. Whether combining kinase
inhibitors with current best first-line therapy can achieve deeper
responses and cure the disease will be addressed in large studies.
The answer to this question is obviously many years in the future.
We may also have to learn new rules of how to best combine drugs.
Combination with chemotherapy seems to be old fashioned, but
may work well because the mechanism of action is so different and
there is a great deal of experience with chemotherapeutic agents.
Dual kinase inhibitor therapy to hit 2 nodes in the pathway
simultaneously could be more powerful, but likewise could also be
more disruptive for normal cells. Combinations with other investigational agents may be mechanistically attractive, but combine 2
unknowns. Finally, a combination of immunotherapeutic approaches and kinase inhibitors could deliver an elegant one-two
punch approach, but kinase inhibitors appear to change the
immune system and these changes are still ill defined.
Rarely in CLL have there been so many good reasons to explore
very different strategies. Therefore, it is particularly important to
encourage all patients to participate in clinical trials to define the
pros and cons of different approaches, which can then serve as
the basis for individualized therapy. Clinical trials ongoing in the
United States are registered at www.clinicaltrials.gov.

Should kinase inhibitors become the preferred treatment

for everybody?
The greatest benefit of kinase inhibitors is seen in patients who have
exhausted other treatment options and now suddenly have access to
new and powerful medications that can turn dire situations around.
Durability of response remains to be better defined, and, at least for
younger patients having high-risk disease and an available wellmatched donor, treatment with a kinase inhibitor followed by
allogeneic transplantation may provide better long-term disease
control than drug therapy alone.
Randomized clinical trials investigating kinase inhibitors as firstline therapy for CLL are ongoing.101 At this time, limited data
suggest that patients who are unable to tolerate standard chemoimmunotherapy or who have del17p may benefit from starting kinase
inhibitors in first-line.63,64,74 Conversely, maturing data with FCR
(fludarabine cyclophosphamide rituximab) suggest that a subset of patients can have long-lasting deep remissions, raising the

Hematology 2014

possibility that a proportion of patients are cured with FCR.9,102 In

the M.D. Anderson experience, 35% of the patients in the initial
cohort were alive and relapse-free 10 years from starting FCR.
Further, a subset of these patients, tested with flow cytometry, was
found to have no residual disease! Although many of these patients
had lower-risk disease at the initiation of treatment (M-CLL, Rai
stage 3, serum 2-microglobulin 4 mg/dL), these results suggest that up to 1/3 of patients may be cured.102 Therefore, for this
group of patients, the relative benefit of novel agents would have to
be demonstrated with regard to safety and tolerability.

Outlook
One thing is clear: patients with CLL and LPL have novel effective
treatment options that are improving overall survival and quality of
life. For once, patients in greatest need may actually reap the
greatest benefit. For many among them, these novel agents can be
life savers. Other patients already have excellent treatment options
available and the tradeoff between different approaches remains to
be defined. Increasingly, individual preferences and choices may
become important factors in decision making. Unfortunately, the
many options may create some anguish about choosing the best
treatment. On the other hand, it is reassuring that if one treatment
fails, there are other good options that can save the day.

Acknowledgments
The author is supported by the intramural research program of the
National Heart, Lung, and Blood Institute of the National Institutes
of Health.

Disclosures
Conflict-of-interest disclosure: The author has received research
funding from and has consulted for Pharmacyclics. Off-label drug
use: Ibrutinib as first-line treatment of CLL.

Correspondence
Adrian Wiestner, Hematology Branch, NHLBI, NIH, Bldg. 10,
CRC 3-5140, 10 Center Drive, 20892-1202 Bethesda, MD; Phone:
301-496-5093; Fax: 301-496-8396; e-mail: wiestnea@nhlbi.nih.gov.

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