Novel Agents for Chronic Lymphocytic Leukemia to Address Resistance

Novel agents for chronic lymphocytic leukemia (CLL) target specific pathways and mechanisms to overcome drug resistance and improve treatment outcomes. Here’s how they work:

Published in Cancer and Genetics & Genomics

Novel Agents for Chronic Lymphocytic Leukemia to Address Resistance
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Beyond BCL2 (B cell lymphoma) and BTK (Bruton tyrosine kinase) inhibitors: novel agents and resistance mechanisms for chronic lymphocytic leukemia - Discover Oncology

Background Chronic lymphocytic leukemia (CLL) is considered the one of most prevalent hematological diseases in the Western world, with an incidence of 4.2/100 000/year that increases to more than 30/100 000/year at an age of greater than 80 years. The Bruton tyrosine kinase inhibitor ibrutinib has been considered the treatment of choice in treatment naïve and relapsed/refractory settings (R/R). Venetoclax, along with navitoclax, are the selected BCL2 inhibitors in first and second-line settings for chronic lymphocytic leukemia. A degree of acquired resistance for this agents has been observed in clinical settings, and is also determined by scientific rationale. Methods A PubMed literature search and Google Scholar search were conducted using the terms “chronic lymphocytic leukemia” AND “novel therapies”, “BTK degraders”, and “acquired resistance”, and “bispecific antibodies”, and “chimeric antigen T cell therapy.” “ recent phase III trials” and “CLL” AND “MURANO trial” AND “BRUIN trial” AND “CLL14 trial” AND “TRANSCEND trial” AND “updates.” Results Acquired resistance has been extensively documented in treatment of CLL, mainly due to the mutation Gly101Val that leads to displacement of pro-apoptotic proteins. Newer agents identified include pirtobrutinib and nemtabrutinib, non-covalent, reversible BTK inhibitors, the anti-CD20 monoclonal antibodies employing CD20 target antigen mechanisms ofatumumab, obinutuzumab, lisocabtagene maraleucel, a CD19 chimeric antigen T cell receptor therapy, teclistamab, a BsAb that targets the B cell maturation antigen or BCMA and Siglec-6 monoclonal antibodies. Conclusion CLL has demonstrated acquired resistance to BTK inhibitors and BCL2 inhibitors, necessitating the development and evaluating of treatment options beyond their use. Cancer immunotherapies such as bispecific antibodies and chimeric T cell therapies present with viable therapies for CLL. Novel agents have also been developed that enhance the cytotoxic effect of T cells. Future studies may focus on the developing treatments that overcome the acquired resistance that results when treatment with standard of care targeted therapies ibrutinib and venetoclax. Graphical Abstract

BTK Degraders

  • Mechanism: These agents degrade Bruton tyrosine kinase (BTK), a key protein in B-cell receptor signaling, which is essential for CLL cell survival. ​
  • Examples: NX-2127, BGB-16673, and NX-5948 have shown efficacy in relapsed/refractory (R/R) CLL. ​
  1. Non-Covalent BTK Inhibitors
  • Mechanism: These reversible inhibitors target BTK without relying on covalent binding, overcoming resistance caused by mutations like C481S. ​
  • Examples:
    • Pirtobrutinib: Demonstrates high selectivity and efficacy, even in heavily pretreated patients. ​
    • Nemtabrutinib: Similar efficacy but less well-tolerated compared to pirtobrutinib. ​
  1. BH3 Mimetics
  • Mechanism: Mimic pro-apoptotic proteins to inhibit anti-apoptotic BCL2 family proteins, promoting cell death. ​
  • Examples: Venetoclax targets BCL2, while newer agents like sonrotoclax aim to overcome resistance caused by mutations like Gly101Val. ​
  1. Monoclonal Antibodies
  • Mechanism: Target antigens on CLL cells (e.g., CD20, CD19, CD37) to induce apoptosis or recruit immune cells for cytotoxicity. ​
  • Examples:
    • Obinutuzumab: Anti-CD20 antibody with improved efficacy over rituximab. ​
    • Otlertuzumab: Anti-CD37 antibody triggering apoptosis and antibody-dependent cell-mediated cytotoxicity. ​
  1. Bispecific Antibodies
  • Mechanism: Bind both CLL cell antigens (e.g., CD19, CD20, BCMA) and CD3 on T cells, redirecting T cells to kill leukemia cells. ​
  • Examples:
    • Blinatumomab: Targets CD19 and CD3. ​
    • Teclistamab: Targets BCMA and CD3.
  1. Chimeric Antigen Receptor (CAR) T Cell Therapies
  • Mechanism: Genetically modified T cells express CARs targeting antigens like CD19, enabling direct killing of CLL cells. ​
  • Examples: Lisocabtagene maraleucel (CD19 CAR T therapy). ​
  1. Siglec-6 Monoclonal Antibodies
  • Mechanism: Target Siglec-6, a novel antigen absent on healthy cells, to activate T cells and eliminate CLL cells. ​
  • Examples: RC-1 and RC-2 antibodies engineered for high specificity and potency. ​
  1. ROR1-Directed Therapies
  • Mechanism: Target ROR1, a receptor tyrosine kinase expressed selectively on CLL cells. ​
  • Examples: Cirmtuzumab and zilovertamab vedotin.
  1. Vg9Vd2-T Cell Engagers
  • Mechanism: Activate Vg9Vd2-T cells to lyse CLL cells by targeting CD1d, a molecule expressed on leukemic cells. ​
  • Example: Bispecific single-domain antibodies designed to boost T cell responses. ​
  1. Anti-BAFF Antibodies
  • Mechanism: Target BAFF, a factor promoting CLL cell survival, to induce apoptosis. ​
  • Examples: Belimumab and ianalumab.
  1. Precision Medicine Approaches
  • Mechanism: Use predictive biomarkers (e.g., TP53, IGHV mutations) and machine learning algorithms to tailor treatments based on tumor heterogeneity and resistance profiles.

These novel agents address unmet clinical needs by targeting specific pathways, overcoming resistance mechanisms, and enhancing immune responses, offering hope for improved outcomes in CLL treatment.

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Chronic Lymphocytic Leukaemia
Life Sciences > Biological Sciences > Cancer Biology > Cancers > Haematological Cancer > Leukaemia > Chronic Lymphocytic Leukaemia
Targeted Therapies
Life Sciences > Biological Sciences > Cancer Biology > Cancer Therapy > Targeted Therapies
Personalized Medicine
Life Sciences > Biological Sciences > Genetics and Genomics > Medical Genetics > Personalized Medicine
Cancer Immunotherapy
Life Sciences > Biological Sciences > Cancer Biology > Cancer Therapy > Cancer Immunotherapy
  • Discover Oncology Discover Oncology

    This is a fully open access general oncology journal that aims to provide a unified forum for researchers and clinicians. The journal spans from basic and translational science, to preclinical, clinical, and epidemiology, and welcomes content that interfaces at all levels of cancer research.

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