Background: In an academic clinical trial, we are investigating an alternative strategy for ibrutinib dosing in patients with chronic lymphocytic leukemia (CLL) who have received at least 6 months (mo) of therapy and are in stable partial remission (PR). Briefly, treatment is suspended and patients followed off therapy until early signs of progressive disease (PD), at which ibrutinib is re-instituted. Such ‘ON-OFF’ ibrutinib cycles are repeated until resistance and need of alternative therapy. In the phase 1b part of the study, we showed that ibrutinib can safely be suspended (Lundin et al., 2021). A spin-off study runs in parallel with the trial to characterize the cellular and molecular changes induced by this alternative dosing of ibrutinib. Methods. Peripheral blood (PB) samples were collected from 20 patients right before the first treatment interruption (i.e. start of OFF-phase) and at 2 weeks, 1 mo, 3 mo, 6 mo and 12 mo after treatment interruption and before re-start. Pre-treatment samples (i.e. at primary start of ibrutinib) were also available for 11/20 patients while samples taken before re-start of treatment (i.e. start of ON-phase) were available for 10/20 patients. Flow cytometry analysis of the different T- and NK-cells subsets was performed and plasma inflammation-related biomarkers were assessed by a proximity extension assay. Quantitative digital-droplet PCR is ongoing to detect the occurrence of mutations within BTK and PLCG2 on samples taken before treatment stop and at re-start. Results: After treatment interruption, CLL cells remained stable until time for re-start when they increased (p<0.0005). The same dynamics were observed for CD8+ and CD4+ cells (p=0.03 and p=0.01, respectively) and for Th1 and Th2 cells (p=0.001, respectively). Naïve CD4+ T cells (CCR7+CD45RA+) remained stable throughout the OFF phase until re-start. CD4+ central memory (CM) T cells (CCR7+CD45RA-) started increasing at mo 6 (p=0.03) and were still higher at re-start (p=0.007). Effector memory (EM) CD4+ T cells (CCR7-CD45RA-) remained stable until re-start (p=0.03). CD4+ T effector memory re-expressing CD45RA (TEMRA; CCR7-CD45RA+) decreased at mo 3 after stop (p=0.01) until mo 12 (p=0.004) but increased again at re-start. Remarkably, regulatory T cells (Tregs) started increasing earlier compared to the other cell populations, from 3 mo (p= 0.02) and progressively more significantly until re-start (p= 0.001). NK cells decreased initially (p= 0.04 at wk 2) and later increased from 12 mo to restart (p=0.003). The expression of all exhaustion markers on T cells increased at re-start: CD4+PD-1+ (p=0.005), CD8+PD-1+ (p=0.002), CTLA-4+CD4+ (p=0.005), CTLA-4+CD8+ (p=0.02), TIGIT+CD4+ (p=0.002), TIGIT+CD8+ (p=0.002). When analyzing 92 inflammatory plasma protein biomarkers, we observed the following patterns: 1) some markers which had decreased during treatment, increased again in the OFF-phase, such as CCL3 and CCL4; 2) some markers which had increased during ibrutinib treatment, significantly decreased in the OFF-phase, such as AREG, TNFSF13, EDAR, CST5; 3) some markers which had decreased during treatment, stayed at low levels in the OFF-phase, such as VIM, NT3, NF2, IRAK4, BACH1 and FGF2. The markers in the first group were the majority. Changes were considered statistically significant when the adjusted p-value was <0.05. Conclusions. After interruption of ibrutinib, the immune cell phenotype achieved after long-term treatment seems to remain substantially stable until PD occurs, at which the phenotype reverts to the pre-treatment one.Similarly, the majority of the changes in plasma protein biomarkers acquired with treatment gradually revert to the pre-treatment status. However, a minority of them remained unchanged despite PD, for reasons to be investigated.

Background Immunocompromised patients with primary and secondary immunodeficiencies have shown impaired responses to SARS-CoV-2 mRNA vaccines, necessitating recommendations for additional booster doses. However, longitudinal data reflecting the real-world impact of such recommendations remains limited. Methods This study represents a two-year follow-up of the COVAXID clinical trial, where 364 of the original 539 subjects consented to participate. 355 individuals provided blood samples for evaluation of binding antibody (Ab) titers and pseudo-neutralisation capacity against both the ancestral SARS-CoV-2 strain and prevalent Omicron variants. T cell responses were assessed in a subset of these individuals. A multivariate analysis determined the correlation between Ab responses and the number of vaccine doses received, documented infection events, immunoglobulin replacement therapy (IGRT), and specific immunosuppressive drugs. The original COVAXID clinical trial was registered in EudraCT (2021-000175-37) and clinicaltrials.gov (NCT04780659). Findings Several of the patient groups that responded poorly to the initial primary vaccine schedule and early booster doses presented with stronger immunogenicity-related responses including binding Ab titres and pseudo-neutralisation at the 18- and 24-month sampling time point. Responses correlated positively with the number of vaccine doses and infection. The vaccine response was blunted by an immunosuppressive state due to the underlying specific disease and/or to specific immunosuppressive treatment. Interpretation The study results highlight the importance of continuous SARS-CoV-2 vaccine booster doses in building up and sustaining Ab responses in specific immunocompromised patient populations. Funding The present studies were supported by the European Research Council, Karolinska Institutet, Knut and Alice Wallenberg Foundation, Nordstjernan AB, Region Stockholm, and the Swedish Research Council.

T cells are critical in mediating the early control of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) breakthrough infection. However, it remains unknown whether memory T cells can effectively cross-recognize new SARS-CoV-2 variants with a broad array of mutations, such as the emergent hypermutated BA.2.86 variant. Here, we report in two separate cohorts, including healthy controls and individuals with chronic lymphocytic leukemia, that SARS-CoV-2 spike-specific CD4+ and CD8+ T cells induced by prior infection or vaccination demonstrate resilient immune recognition of BA.2.86. In both cohorts, we found largely preserved SARS-CoV-2 spike-specific CD4+ and CD8+ T cell magnitudes against mutated spike epitopes of BA.2.86. Functional analysis confirmed that both cytokine expression and proliferative capacity of SARS-CoV-2 spike-specific T cells to BA.2.86-mutated spike epitopes are similarly sustained. In summary, our findings indicate that memory CD4+ and CD8+ T cells continue to provide cell-mediated immune recognition to highly mutated emerging variants such as BA.2.86.

Background: Patients with chronic lymphocytic leukemia (CLL) exhibit considerable risk of severe infections already prior to needing treatment. Despite this, clinical tools identifying patients-at-risk are an unmet need along with management strategies for high-risk CLL patients who do not fulfill iwCLL treatment criteria. PreVent-ACaLL (NCT03868722) is a phase 2 clinical trial applying the machine learning-based CLL treatment infection model (CLL-TIM) to identify newly diagnosed CLL patients with high risk of severe infections and/or early treatment (Agius et al., Nat Comm, 2020). High-risk patients are randomized between 3 cycles of preemptive acalabrutinib+venetoclax (A+V) or watch and wait (WW). We recently demonstrated that CLL patients needing treatment exhibited innate immune dysfunction characterized by excessive granulocyte activation and monocyte “exhaustion” with skewed cytokine response to toll-like receptor (TLR) stimulation. Immune function was restored upon treatment with BTK- and BCL2 inhibitors in parallel with a reduced infectious burden (Teglgaard et al., CCR, 2024). We here investigate innate immune dysfunction changes upon preemptive A+V or WW in context of the PreVent-ACaLL phase 2 trial. Methods: Fifteen patients included thus far in PreVent-ACaLL were randomized 1:1 between preemptive A+V or WW. Blood samples were assessed at baseline, after 12 weeks (end of treatment), and after 24 weeks. Innate immune function was assessed in fresh whole-blood samples by TruCulture, a clinically implemented functional assay quantifying cytokine release in response to standardized immune stimuli (lipopolysaccharide [LPS] for TLR4; single-stranded RNA-virus analogue resiquimod [R848] for TLR7/8) and an unstimulated control. Concurrently, extensive immunophenotyping of immune cell subsets in fresh whole blood was assessed by an 8-tube, 10 color flow cytometry panel (DuraClone). Baseline data were compared to previous data from 35 CLL patients needing treatment (outside the trial). All patients provided written informed consent, and the study was approved by the Ethics Committee and the Data Protections Agency. Results: At baseline, LPS- and R848 stimulated release of IFN-γ and IL-10 was reduced and R848-stimulated release of IL-8 and TNF-α was elevated in CLL patients included in PreVent-ACaLL (n=15) compared to normal reference levels, with cytokine levels comparable to CLL patients needing treatment. Unstimulated IL-8 and TNF-α were also elevated in PreVent-ACaLL patients, similar to- or exceeding the levels observed for CLL patients needing treatment. In the treatment arm (n=8), R848-stimulated IL-10 release normalized during the 24 weeks (p=0.02). R848 stimulated- and unstimulated IL-8 and TNF-α normalized upon A+V while remaining elevated in patients from the WW arm (n=7) (A+V vs WW at 24 weeks: p=0.02 [R848-IL8], 0.04 [R848-TNFα], and 0.04 [Unstim-IL-8]). Notably, normalization of unstimulated cytokines first occurred at 24 weeks (12 weeks post treatment). Immunophenotyping data will be included for the presentation. Conclusion: Functional immune assessment of the first fifteen patients enrolled in the phase 2 PreVent-ACaLL trial for newly diagnosed patients with CLL at high risk of infection and/or treatment indicates increased inflammatory activity along with dysregulated innate immune responses similar to patients with progressive CLL needing treatment. Despite a small sample size, we observed signs of innate immune restoration and reduced inflammation in patients receiving preemptive A+V for 12 weeks as compared to the WW arm. These findings are coherent with our previous observations of innate immune restoration upon treatment with acalabrutinib monotherapy or ibrutinib+venetoclax in CLL patients needing treatment (Teglgaard et al., CCR, 2024). Thus, we here for the first time provide early data indicating that preemptive treatment may improve immune function and thus reduce infectious risk in high-risk newly diagnosed CLL, further emphasizing the role of data-driven decision support tools for CLL infectious risk assessment and management. The PreVent-ACaLL trial is ongoing, awaiting clinical results within the coming years.

Background/Objectives: Nurse-like cells (NLCs) derived from monocytes in the tumor microenvironment support the growth of chronic lymphocytic leukemia (CLL) cells. Here, we investigated the effects of a CX3CR1 (fractalkine receptor) antagonist (KAND567) on autologous monocytes and their pro-survival effects on CLL cells in vitro. Methods: Plasma concentration of CX3CL1 was determined by ELISA and CX3CR1 expression by flow cytometry. CD19+ cells and autologous monocytes from patients with CLL and healthy donors were treated with KAND567 either in co-culture or alone. The apoptosis of CD19+ cells and monocytes was determined by Annexin V/PI staining and live-cell imaging. Results: Plasma concentration of CX3CL1 (fractalkine) was significantly higher in patients with CLL (n = 88) than in healthy donors (n = 32) (p < 0.0001), with higher levels in patients with active compared to non-active disease (p < 0.01). CX3CR1 was found on monocytes but not B cells in patients and controls. Levels of intermediate and non-classical CX3CR1+ monocytes were higher in patients with CLL than in controls (p < 0.001), particularly in those with active disease (p < 0.0001). Co-culture experiments revealed that autologous monocytes promoted the survival of both malignant and normal B cells and that KAND567 selectively inhibited the growth of CLL cells in a dose-dependent manner but only in the presence of autologous monocytes (p < 0.05). Additionally, KAND567 inhibited the transition of monocytes to NLCs in CLL (p < 0.05). Conclusions: Our data suggest that the CX3CR1/CX3CL1 axis is activated in CLL and may contribute to the NLC-driven growth-promoting effects of CLL cells. KAND567, which is in clinical trials in other disorders, should also be explored in CLL.

Cell membranes undergo biophysical remodelling as an adaptation to the surroundings and to perform specific biological functions. However, the extent and relevance of such changes in human immune systems remain unknown, largely due to the lack of high throughput and multidimensional methodologies. Here, we describe a cytometry-based method with single-cell resolution which fills this technological gap by combining biophysical profiling with conventional biomarker analysis. This platform allows to reveal notable cell type-dependent remodelling of membrane fluidity during immune stimulations and in diseases. Using immune cells exposed to tumour microenvironment as well as from long COVID and chronic lymphocyte leukaemia patients, we demonstrate that membrane fluidity is orthogonal to surface marker expression. Moreover, this biophysical parameter identifies new functional and pathological states of immune cells previously undetected via surface marker profiling alone. Our findings will contribute to a more precise definition of immune cell states based on their biophysical properties and will pave the way for a better understanding of the functional heterogeneity of immune cells.### Competing Interest StatementThe authors have declared no competing interest.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. SEQUOIA (ClinicalTrials.gov identifier: NCT03336333 ) is a phase III, randomized, open-label trial that compared the oral Bruton tyrosine kinase inhibitor zanubrutinib to bendamustine plus rituximab (BR) in treatment-naïve patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). The initial prespecified analysis (median follow-up, 26.2 months) and subsequent analysis (43.7 months) found superior progression-free survival (PFS; the primary end point) in patients who received zanubrutinib compared with BR. At a median follow-up of 61.2 months, median PFS was not reached in zanubrutinib-treated patients; median PFS was 44.1 months in BR-treated patients (hazard ratio [HR], 0.29; one-sided P = .0001). Prolonged PFS was seen with zanubrutinib versus BR in patients with mutated immunoglobulin heavy-chain variable region (IGHV) genes (HR, 0.40; one-sided P = .0003) and unmutated IGHV genes (HR, 0.21 [95% CI, 0.14 to 0.33]; one-sided P < .0001). Median overall survival (OS) was not reached in either treatment arm; estimated 60-month OS rates were 85.8% and 85.0% in zanubrutinib- and BR-treated patients, respectively. No new safety signals were detected. Adverse events were as expected with zanubrutinib; rate of atrial fibrillation was 7.1%. At a median follow-up of 61.2 months, the results supported the initial SEQUOIA findings and suggested that zanubrutinib was a favorable treatment option for untreated patients with CLL/SLL.

The ROR1 receptor tyrosine kinase is expressed in embryonic tissues but is absent in normal adult tissues. ROR1 is of importance in oncogenesis and is overexpressed in several cancers, such as NSCLC. In this study, we evaluated ROR1 expression in NSCLC patients (N = 287) and the cytotoxic effects of a small molecule ROR1 inhibitor (KAN0441571C) in NSCLC cell lines. ROR1 expression in tumor cells was more frequent in non-squamous (87%) than in squamous (57%) carcinomas patients, while 21% of neuroendocrine tumors expressed ROR1 (p = 0.0001). A significantly higher proportion of p53 negative patients in the ROR1(+) group than in the p53 positive non-squamous NSCLC patients (p = 0.03) was noted. KAN0441571C dephosphorylated ROR1 and induced apoptosis (Annexin V/PI) in a time- and dose-dependent manner in five ROR1(+) NSCLC cell lines and was superior compared to erlotinib (EGFR inhibitor). Apoptosis was confirmed by the downregulation of MCL-1 and BCL-2, as well as PARP and caspase 3 cleavage. The non-canonical Wnt pathway was involved. The combination of KAN0441571C and erlotinib showed a synergistic apoptotic effect. KAN0441571C also inhibited proliferative (cell cycle analyses, colony formation assay) and migratory (scratch wound healing assay) functions. Targeting NSCLC cells by a combination of ROR1 and EGFR inhibitors may represent a novel promising approach for the treatment of NSCLC patients.

Background: ZANU is a next-generation Bruton tyrosine kinase inhibitor (BTKi) designed to minimize off-target binding and limit associated side effects that is approved in the US and EU for CLL/SLL. Results from the SEQUOIA study (NCT03336333), at a median follow-up of 26.2 mo, demonstrated superior progression-free survival (PFS) by independent review for ZANU vs BR in pts with treatment-naïve (TN) CLL/SLL without (w/o) del(17p); pts with del(17p) treated with ZANU in a separate cohort had similar outcomes to pts w/o del(17p). Aims: To report updated efficacy and safety results from the SEQUOIA study after approximately 18 mo of additional follow-up (data cutoff 31 Oct 2022). Methods: Patients w/o del(17p) were randomized to receive ZANU or BR. Pts with del(17p) were assigned to ZANU monotherapy. Investigator-assessed (INV) PFS, overall survival (OS), overall response rate (ORR) and safety/tolerability were evaluated. Adverse events (AEs) were collected until disease progression or start of next-line therapy. Results: A total of 479 pts w/o del(17p) were randomized to receive ZANU (n=241) or BR (n=238). At a median follow-up of 43.7 mo (range: 0–60 mo), median PFS was not reached for ZANU; however, for BR median PFS was 42.2 mo (HR 0.30; 95% CI: 0.21, 0.43; Figure). At 42 mo, estimated PFS rates were 82.4% for ZANU. With additional follow-up, PFS for ZANU vs BR was now improved for pts with mutated IGHV (HR 0.35; 95% CI: 0.19, 0.64); benefit was also sustained for pts with unmutated IGHV (HR 0.23; 95% CI: 0.14, 0.37) or del(11q) (HR 0.26; 95% CI: 0.13, 0.51). Complete response/complete response with incomplete hematological recovery (CR/CRi) rates in pts w/o del(17p) were 17.4% and 21.8% with ZANU and BR, respectively. While median OS was not reached in either arm, HR for OS was 0.87 (95% CI: 0.50, 1.48) for ZANU vs BR, and estimated 42-month rates were 89.4% and 88.3%, respectively. For 110 pts with del(17p) assigned to ZANU monotherapy, after a median follow-up of 47.9 mo, the estimated 42-month PFS and OS rates were 79.4% and 89.5%, respectively. In this population, the CR/CRi rate was 14.5%. As of 31 Oct 2022, ZANU treatment was ongoing in 74.7% pts w/o del(17p) and 70.3% pts with del(17p). The most common causes for treatment discontinuation were AEs and progressive disease for both those w/o del(17p) (14.9%, 5.8%) and with del(17p) (13.5%, 13.5%, respectively). AEs of interest (AEI), using pooled terms, were as expected for the class in the pts w/o del(17p) (ZANU vs BR). AEI included any grade (gr) atrial fibrillation/flutter (5.0% vs 2.6%), hypertension (17.5% vs 13.7%), bleeding (48.8% vs 12.3%), infection (72.9% vs 62.6%), anemia (7.1% vs 20.7%), thrombocytopenia (6.3% vs 18.1%), and neutropenia (16.7% vs 56.8%). Additionally, Gr≥3 AEI included bleeding (5.8% vs 1.8%), infection (23.8% vs 22.0%), anemia (0.4% vs 2.2%), thrombocytopenia (2.1% vs 7.9%), and neutropenia (12.5% vs 51.1%). Summary/Conclusion: With extended follow-up in the SEQUOIA study, the efficacy of ZANU was maintained in pts w/o del(17p) with a safety profile aligned with long term follow-up for the BTKi class. In addition to the previously reported benefit in pts with unmutated IGHV, longer follow-up now shows benefit in those with mutated IGHV as well, and pts with del(17p) continue to demonstrate PFS benefits consistent with the randomized cohort. Rates of atrial fibrillation remain low and no new safety signals were identified. ZANU continues to be well tolerated over time with low rates of treatment discontinuation and remains a valuable frontline treatment option for CLL/SLL.Keywords: Chronic lymphocytic leukemia, Bruton’s tyrosine kinase inhibitor (BTKi)

PURPOSE In GLOW, fixed-duration ibrutinib + venetoclax showed superior progression-free survival (PFS) versus chlorambucil + obinutuzumab in older/comorbid patients with previously untreated chronic lymphocytic leukemia (CLL). The current analysis describes minimal residual disease (MRD) kinetics and any potential predictive value for PFS, as it has not yet been evaluated for ibrutinib + venetoclax treatment. METHODS Undetectable MRD (uMRD) was assessed by next-generation sequencing at <1 CLL cell per 10,000 (<10−4) and <1 CLL cell per 100,000 (<10−5) leukocytes. PFS was analyzed by MRD status at 3 months after treatment (EOT+3). RESULTS Ibrutinib + venetoclax achieved deeper uMRD (<10−5) rates in bone marrow (BM) and peripheral blood (PB), respectively, in 40.6% and 43.4% of patients at EOT+3 versus 7.6% and 18.1% of patients receiving chlorambucil + obinutuzumab. Of these patients, uMRD (<10−5) in PB was sustained during the first year post-treatment (EOT+12) in 80.4% of patients receiving ibrutinib + venetoclax and 26.3% receiving chlorambucil + obinutuzumab. Patients with detectable MRD (dMRD; ≥10−4) in PB at EOT+3 were more likely to sustain MRD levels through EOT+12 with ibrutinib + venetoclax versus chlorambucil + obinutuzumab. PFS rates at EOT+12 were high among patients treated with ibrutinib + venetoclax regardless of MRD status at EOT+3: 96.3% and 93.3% in patients with uMRD (<10−4) and dMRD (≥10−4) in BM, respectively, versus 83.3% and 58.7% for patients receiving chlorambucil + obinutuzumab. PFS rates at EOT+12 also remained high in patients with unmutated immunoglobulin heavy-chain variable region (IGHV) receiving ibrutinib + venetoclax, independent of MRD status in BM. CONCLUSION Molecular and clinical relapses were less frequent during the first year post-treatment with ibrutinib + venetoclax versus chlorambucil + obinutuzumab regardless of MRD status at EOT+3 and IGHV status. Even for patients not achieving uMRD (<10−4), PFS rates remained high with ibrutinib + venetoclax; this is a novel finding and requires additional follow-up to confirm its persistence over time.

PDF file - 106K, Immunoblot analysis of the indicated proteins in U-266 and LP-1 pre-treated with 10 muM CQ, 10 muM zVAD.fmk or 4 muM MG132 (for 4h) followed by 10 mu M Sor for 24h

Key Points • One-third of patients with CLL relapsing on ibrutinib do not carry BTK/PLCG2 mutations, even with a 0.1% sensitivity.• Additional mechanisms, such as del(8p), EGR2 and NF-κB pathway mutations, may be cooperating in determining progression on ibrutinib.

<p>PDF file - 106K, Immunoblot analysis of the indicated proteins in U-266 and LP-1 pre-treated with 10 muM CQ, 10 muM zVAD.fmk or 4 muM MG132 (for 4h) followed by 10 mu M Sor for 24h</p>

PDF file - 26K, The indicated myeloma cell lines were treated with 10 muM Sor for 24h and cell cycle distribution was analysed by NucleoCounter NC-3000 (Chemometec).

T cells are critical for immune protection against severe COVID-19, but it has remained unclear whether repeated exposure to SARS-CoV-2 antigens delivered in the context of vaccination fuels T cell exhaustion or reshapes T cell functionality. Here, we sampled convalescent donors with a history of mild or severe COVID-19 before and after SARS-CoV-2 vaccination to profile the functional spectrum of hybrid T cell immunity. Using combined single-cell technologies and high-dimensional flow cytometry, we found that the frequencies and functional capabilities of spike-specific CD4 + and CD8 + T cells in previously infected individuals were enhanced by vaccination, despite concomitant increases in the expression of inhibitory receptors such as PD-1 and TIM3. In contrast, CD4 + and CD8 + T cells targeting non-spike proteins remained functionally static and waned over time, and only minimal effects were observed in healthy vaccinated donors experiencing breakthrough infections with SARS-CoV-2. Moreover, hybrid immunity was characterized by elevated expression of IFN-γ, which was linked with clonotype specificity in the CD8 + T cell lineage. Collectively, these findings identify a molecular hallmark of hybrid immunity and suggest that vaccination after infection is associated with cumulative immunological benefits over time, potentially conferring enhanced protection against subsequent episodes of COVID-19.

Background: In the GLOW study (NCT03462719), fixed-duration Ibr+Ven demonstrated superior progression-free survival (PFS), deeper, better sustained undetectable minimal residual disease (uMRD) responses, and fewer patients (pts) requiring subsequent anti-cancer treatment versus Clb+O in older and/or comorbid pts with previously untreated chronic lymphocytic leukemia (CLL; Kater AP, et al. NEJM Evidence. 2022). Unmutated IGHV (uIGHV) and TP53 mutations are risk factors associated with worse outcomes for both chemoimmunotherapy and venetoclax plus anti-CD20 therapies for CLL. Here we investigate MRD kinetics and outcomes of Ibr+Ven in GLOW according to these risk factors. Methods: Pts aged ≥ 65 years or 18 to 64 years with cumulative illness rating scale score > 6 or creatinine clearance < 70 mL/min were enrolled and randomized 1:1 to Ibr+Ven (3 cycles of Ibr lead-in, followed by 12 cycles of Ibr+Ven) or 6 cycles of Clb+O, with a cycle defined as 28 days. Pts with del(17p) or known TP53 mutations at screening were excluded, and central evaluation of TP53 mutational status was performed during the study. The primary end point was PFS by independent review committee. Among pts with partial response or better, MRD in peripheral blood was evaluated using next-generation sequencing via clonoSEQ on-treatment and at 3-6 month intervals post-treatment. uMRD results are reported in peripheral blood (PB) at < 10-4 unless otherwise noted. Since the primary analysis, a post hoc retrospective reclassification of the IGHV status of baseline samples was conducted to reduce the number of unknowns. We used clonoSEQ data as part of CLL clonal testing (Adaptive Biotechnologies, Seattle, WA). Results: There were 106 pts randomized to Ibr+Ven and 105 to Clb+O. In the Ibr+Ven arm, uMRD rates increased from 46.2% after 6 cycles of the combination to 54.7% at 3 months after end of treatment (EOT+3), demonstrating that the majority of disease clearance in the PB occurred early, during the first 6 months of combination treatment. Post-treatment, 77.6% (45/58) of pts in the Ibr+Ven arm sustained their uMRD status from EOT+3 to EOT+18, compared with 12.2% (5/41) in the Clb+O arm. In the Ibr+Ven arm, 17/24 patients with intermediate MRD ≥ 10-4 to < 10-2 at EOT+3 did not worsen through EOT+18. Among pts with detectable MRD (≥ 10-4) at EOT+3, 6.5% (2/31) clinically progressed by EOT+18 in the Ibr+Ven arm versus 68.1% (32/47) in the Clb+O arm. After reclassification of baseline samples, uIGHV / mutated IGHV (mIGHV) / unknown status was 63.2%/30.2%/6.6% in the Ibr+Ven arm and 54.3%/33.3%/12.4% in the Clb+O arm. In the Ibr+Ven arm, rates of uMRD after 6 cycles of combination treatment and at EOT+3, respectively, were 52.2% and 59.7% in pts with uIGHV and 31.3% and 40.6% in pts with mIGHV (Fig A). On-treatment MRD kinetics differed by IGHV status in the Ibr+Ven arm, with uMRD achieved at a higher rate and earlier in pts with uIGHV. In the Ibr+Ven arm, uMRD was sustained post-treatment (from EOT+3 and EOT+18) in 80.0% (32/40) of pts with uIGHV and 76.9% (10/13) of pts with mIGHV. Among pts with detectable MRD (≥ 10-4) at EOT+3, 2/16 with uIGHV and 0/14 with mIGHV had clinically progressed by EOT+18 in the Ibr+Ven arm; corresponding rates were 83.3% (25/30) and 42.9% (6/14) in the Clb+O arm. Five of 7 pts with TP53-mutated CLL achieved uMRD at EOT+3 in the Ibr+Ven arm; TP53 variant allele frequencies ranged between 5.9% and 29.6% for these 5 pts and all maintained uMRD through EOT+18. With a median study follow-up of 34.1 months, PFS rates after IGHV reclassification were well sustained post-treatment regardless of IGHV status in the Ibr+Ven arm, while uIGHV pts in the Clb+O arm relapsed more quickly (Fig B). PFS, overall survival, and subgroup analyses with longer study follow-up will be presented. Conclusion: All-oral, once-daily, fixed-duration Ibr+Ven achieved uMRD responses that were better sustained than Clb+O during the first 18 months post-treatment. Notably, with Ibr+Ven, uMRD rates were higher and achieved earlier in pts with uIGHV CLL versus mIGHV CLL, while uMRD was similarly sustained post-treatment irrespective of IGHV status. Clinical progressions in the first 18 months post-treatment with Ibr+Ven were uncommon even among pts with detectable MRD ≥ 10-4. MRD kinetics and sustained responses demonstrate strong efficacy of the fixed-duration Ibr+Ven combination in older pts with high-risk genomic features. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Introduction: Zanu, a next-generation Bruton tyrosine kinase inhibitor (BTKi), demonstrated superior progression-free survival (PFS) by independent review versus BR in pts with TN CLL/SLL without (w/o) del(17p) in the SEQUOIA study (NCT03336333) at a median follow-up of 26.2 mo; pts with del(17p) treated with zanu in a separate cohort had similar outcomes to pts w/o del(17p). Here, updated efficacy and safety results from the SEQUOIA study after 18 mo of additional follow-up (data cutoff 31 October 2022) are reported. Methods: Patients w/o del(17p) were randomized to zanu or BR. Pts with del(17p) received zanu monotherapy. Investigator-assessed PFS, overall survival (OS), overall response rate, and safety/tolerability were evaluated. Results: A total of 479 pts w/o del(17p) were randomized (zanu: n = 241; BR: n = 238). At a median follow-up of 43.7 mo, median PFS was not reached (NR) for zanu and was 42.2 mo for BR (Figure). At 42 mo, estimated PFS rates were 82% for zanu. With additional follow-up, PFS for zanu versus BR was improved for pts with mutated IGHV (HR 0.35; 95% CI: 0.19, 0.64); benefit was also sustained for pts with unmutated IGHV (HR 0.23; 95% CI: 0.14, 0.37) or del(11q) (HR 0.26; 95% CI: 0.13, 0.51). Complete response/complete response with incomplete hematological recovery (CR/CRi) rates in pts w/o del(17p) were 17% and 22% with zanu and BR, respectively. While median OS was NR in either arm, HR for OS was 0.87 (95% CI: 0.50, 1.48) for zanu versus BR, and estimated 42-mo rates were 89% versus 88%, respectively. For pts with del(17p) assigned to zanu monotherapy, after a median follow-up of 47.9 mo, the estimated 42-mo PFS and OS rates were 79% and 90%, respectively; the CR/CRi rate was 15%. As of 31 Oct 2022, zanu treatment was ongoing in 75% pts w/o del(17p) and 70% pts with del(17p). The most common causes for treatment discontinuation were adverse events (AEs) and progressive disease for pts w/o del(17p) (15%, 6%) and with del(17p) (14%, 14%, respectively). AEs of interest (AEI) in pts w/o del(17p) (zanu vs. BR) included any-grade (gr) atrial fibrillation/flutter (5% vs. 3%), hypertension (18% vs. 14%), bleeding (49% vs. 12%), infection (73% vs. 63%), anemia (7% vs. 21%), thrombocytopenia (6% vs. 18%), and neutropenia (17% vs. 57%). Gr≥3 AEI included bleeding (6% vs. 2%), infection (24% vs. 22%), anemia (1% vs. 2%), thrombocytopenia (2% vs. 8%), and neutropenia (13% vs. 51%). Encore Abstract—previously submitted to EHA 2023 The research was funded by: BeiGene Keyword: chronic lymphocytic leukemia (CLL) Conflicts of interests pertinent to the abstract M. Shadman Consultant or advisory role: AbbVie, Genentech, AstraZeneca, Sound Biologics, Pharmacyclics, BeiGene, Bristol Myers Squibb, Morphosys/Incyte, TG Therapeutics, Innate Pharma, Kite Pharma, Adaptive Biotechnologies, Epizyme, Eli Lilly, Adaptimmune, Mustang Bio, Regeneron, Merck, Fate Therapeutics, MEI Pharma and Atara Biotherapeutics Research funding: Mustang Bio, Celgene, Bristol Myers Squibb, Pharmacyclics, Gilead, Genentech, AbbVie, TG Therapeutics, BeiGene, AstraZeneca, Sunesis, Atara Biotherapeutics, Genmab, Morphosys/Incyte T. Munir Consultant or advisory role: Janssen, AbbVie, Lilly, AstraZeneca, BeiGene, Alexion, Sobi, Novartis Honoraria: Janssen, AbbVie, AstraZeneca, Roche, Sobi, Alexion Educational grants: Janssen, AbbVie, AstraZeneca T. Roback Honoraria: AstraZeneca, BeiGene, Janssen, AbbVie, Octapharma, Regeneron, GSK Research funding: BeiGene, OctaPharma, AstraZeneca, Janssen, Regeneron, GSK Educational grants: AstraZeneca J. R. Brown Consultant or advisory role: Abbvie, Acerta/Astra-Zeneca, BeiGene, Genentech/Roche, Grifols Worldwide Operations, Hutchmed, iOnctura, Janssen, Kite, Loxo/Lilly, MEI Pharma, Numab Therapeutics, Pfizer, Pharmacyclics Research funding: BeiGene, Gilead, iOnctura, Loxo/Lilly, MEI Pharma, TG Therapeutics B. S. Kahl Consultant or advisory role: Genentech, ADCT, AbbVie, AstraZeneca, BeiGene, Pharmacyclics, BMS, TG Therapeutics, Teva, Janssen, MEI Research funding: Genentech, ADCT, AbbVie, Acerta, AstraZeneca, BeiGene P. Ghia Consultant or advisory role: AbbVie, AstraZeneca, BeiGene, BMS; Janssen, Lilly/Loxo Oncology, MSD, Roche Honoraria: AbbVie, AstraZeneca, BeiGene, BMS; Janssen, Lilly/Loxo Oncology, MSD, Roche Research funding: AbbVie, AstraZeneca, BMS, Janssen K. Giannopoulos Employment or leadership position: Next Generation Hematology Consultant or advisory role: AbbVie, Amgen, AstraZeneca, BeiGene, GSK, Janssen, Novartis, Takeda, Roche, Gilead, Sandoz Honoraria: AbbVie, Amgen, AstraZeneca, BeiGene, Janssen, Novartis, Takeda, Roche, Karyopharm, GSK, Gilead, Sandoz, Pfizer, Teva Research funding: AbbVie, Amgen, AstraZeneca, Janssen, Sanofi-Genzyme, Novartis, Takeda, Roche Educational grants: Sanofi-Genzyme, Roche, Janssen M. Šimkovič Consultant or advisory role: AbbVie, AstraZeneca, Janssen-Cilag Stock ownership: AbbVie, AstraZeneca, J&J, BeiGene, Gilead, Baxter, Novartis, Abbot, Sanofi Honoraria: AbbVie, Janssen-Cilag, AstraZeneca Educational grants: AbbVie, Janssen-Cilag, AstraZeneca S. Opat Consultant or advisory role: AbbVie, BeiGene, AstraZeneca, BMS, CSL Behring, Gilead. Janssen, Merck, Roche, Takeda Honoraria: AbbVie, BeiGene, AstraZeneca, BMS, CSL Behring, Gilead. Janssen, Merck, Roche, Takeda Research funding: AbbVie, AstraZeneca, BeiGene, CSL Behring, Gilead. Janssen, Merck, Pharmacyclics, Roche, Takeda R. Greil Consultant or advisory role: Celgene, Novartis, Roche, BMS, Takeda, AbbVie, AstraZeneca, Janssen, MSD, Merck, Gilead, Daiichi Sankyo, Sanofi Honoraria: Celgene, Roche, Merck, Takeda, AstraZeneca, Novartis, Amgen, BMS, MSD, Sandoz, AbbVie, Gilead, Daiichi Sankyo, Sanofi Research funding: Celgene, Roche, Merck, Takeda, AstraZeneca, Novartis, Amgen, BMS, MSD, Sandoz, AbbVie, Gilead, Daiichi Sankyo Educational grants: Roche, Amgen, Janssen, AstraZeneca, Novartis, MSD, Celgene, Gilead, BMS, Abbvie, Daiichi Sankyo M. Trněný Employment or leadership position: First Faculty of Medicine, Charles University General Hospital in Prague Consultant or advisory role: Janssen, Gilead Sciences, Takeda, Bristol-Myers Squibb, Amgen, AbbVie, Roche, MorphoSys, Incyte, Novartis, Portolla Honoraria: Janssen, Gilead Sciences, Bristol-Myers Squibb, Amgen, AbbVie, Roche, AstraZeneca, MorphoSys, Incyte, Portolla, Takeda, Novartis Educational grants: Gilead, Takeda, Bristol-Myers Squibb, Roche, Janssen, AbbVie D. Brander Consultant or advisory role: AbbVie, Genentech, Pharmacyclics, Pfizer, TG Therapeutics, Verastem Research funding: AbbVie, ArQule, Ascentage, AstraZeneca, BeiGene, DTRM, Genetech, Juno/Celgene/BMS, LOXO, MEI Pharma, Novaris, Pharmacyclics, TG Therapeutics Other remuneration: NCCN panel member I. W. Flinn Consultant or advisory role: AbbVie, AstraZeneca, BeiGene, Century Therapeutics, Genentech, Genmab, Hutchison MediPharma, Iksuda Therapeutics, InnoCare Pharma, Janssen, Kite Pharma, MorphoSys, Myeloid Therapeutics, Novartis, Nurix Therapeutics, Pharmacyclics, Roche, Secura Bio, Servier Pharmaceuticals, Takeda, TG Therapeutics, Verastem, Vincerx Pharma, Xencor Research funding: AbbVie, Acerta Pharma, Agios, ArQule, AstraZeneca, BeiGene, Biopath, Bristol Myers Squibb, CALIBR, CALGB, Celgene, City of Hope National Medical Center, Constellation Pharmaceuticals, Curis, CTI Biopharma, Epizyme, Fate Therapeutics, Forma Therapeutics, Forty Seven, Genentech, Gilead Sciences, InnoCare Pharma, IGM Biosciences, Incyte, Infinity Pharmaceuticals, Janssen, Kite Pharma, Loxo, Merck, Millennium Pharmaceuticals, MorphoSys, Myeloid Therapeutics, Novartis, Nurix, Pfizer, Pharmacyclics, Portola Pharmaceuticals, Rhizen Pharmaceuticals, Roche, Seattle Genetics, Tessa Therapeutics, TCR2 Therapeutics, TG Therapeutics, Trillium Therapeutics, Triphase Research & Development Corp., Unum Therapeutics, Verastem, 2seventy bio E. Verner Research funding: Janssen Cilag A. Tedeschi Employment or leadership position: Department of Hematology Niguarda Hospital Milano Consultant or advisory role: Janssen spa, AstraZeneca, BeiGene, AbbVie Other remuneration: Speakers Bureau: Janssen spa S. De Guibert Honoraria: Janssen, AbbVie, Gilead, AstraZeneca K. Laribi Employment or leadership position: BeiGene, AbbVie, AstraZeneca, Novartis, Takeda Consultant or advisory role: BeiGene Honoraria: Seagen, BeiGene, AbbVie, Takeda Research funding: Novartis, BeiGene, AbbVie, Janssen T. Tian Employment or leadership position: BeiGene Stock ownership: BeiGene V. Ramakrishnan Employment or leadership position: BeiGene Stock ownership: BeiGene Y. Liu Employment or leadership position: BeiGene Ltd. Stock ownership: BeiGene Ltd. Educational grants: BeiGene Ltd. A. Szeto Employment or leadership position: BeiGene Stock ownership: BeiGene J. Paik Employment or leadership position: BeiGene Stock ownership: BeiGene A. Cohen Employment or leadership position: BeiGene Stock ownership: BeiGene Educational grants: BeiGene C. S. Tam Honoraria: Janssen, AbbVie, BeiGene, LOXO, AstraZeneca Research funding: Janssen, AbbVie, BeiGene W. Jurczak Research funding: AbbVie, AstraZeneca, BeiGene, Celgene, Debbiopharm, Epizyme, Incyte, Janssen, Merck, Roche, Takeda, TG Therapeutics

PDF file - 36K, A, Quantitative analysis of Annexin V/PI positive murine 5T33MMvitro cells treated the indicated concentrations of sorafenib for 24h and 48h; B, Immunoblot analysis of the indicated proteins from the 5T33MMvitro cell line treated with 10 muM Sor for the indicated time points. C, Immunoblot analysis of the indicated proteins from murine 5T33MMvivo treated ex-vivo with 10 muM Sor for 24h