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Wang Y, Tschautscher MA, Rabe KG, Call TG, Leis JF, Kenderian SS, Kay NE, Muchtar E, Van Dyke DL, Koehler AB, Schwager SM, Slager SL, Parikh SA, Ding W. Clinical characteristics and outcomes of Richter transformation: experience of 204 patients from a single center. Haematologica 2019; 105:765-773. [PMID: 31197071 PMCID: PMC7049354 DOI: 10.3324/haematol.2019.224121] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/12/2019] [Indexed: 12/14/2022] Open
Abstract
The natural history, prognostication and optimal treatment of Richter transformation developed from chronic lymphocytic leukemia (CLL) are not well defined. We report the clinical characteristics and outcomes of a large series of biopsy-confirmed Richter transformation (diffuse large B-cell lymphoma or high grade B-cell lymphoma, n=204) cases diagnosed from 1993 to 2018. After a median follow up of 67.0 months, the median overall survival (OS) was 12.0 months. Patients who received no prior treatment for CLL had significantly better OS (median 46.3 vs. 7.8 months; P<0.001). Patients with elevated lactate dehydrogenase (median 6.2 vs. 39.9 months; P<0.0001) or TP53 disruption (median 8.3 vs. 12.8 months; P=0.046) had worse OS than those without. Immunoglobulin heavy chain variable region gene mutation, cell of origin, Myc/Bcl-2 double expression and MYC/BCL2/BCL6 double-/triple-hit status were not associated with OS. In multivariable Cox regression, elevated lactate dehydrogenase [Hazard ratio (HR) 2.3, 95% Confidence Interval (CI): 1.3-4.1; P=0.01], prior CLL treatment (HR 2.0, 95%CI: 1.2-3.5; P=0.01), and older age (HR 1.03, 95%CI: 1.01-1.05; P=0.01) were associated with worse OS. Twenty-four (12%) patients underwent stem cell transplant (20 autologous and 4 allogeneic), and had a median post-transplant survival of 55.4 months. In conclusion, the overall outcome of Richter transformation is poor. Richter transformation developed in patients with untreated CLL has significantly better survival. Stem cell transplant may benefit select patients.
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Affiliation(s)
- Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Kari G Rabe
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Jose F Leis
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ
| | | | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Daniel L Van Dyke
- Division of Laboratory Genetics and Genomics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Susan L Slager
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Wei Ding
- Division of Hematology, Mayo Clinic, Rochester, MN
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Duarte RF, Labopin M, Bader P, Basak GW, Bonini C, Chabannon C, Corbacioglu S, Dreger P, Dufour C, Gennery AR, Kuball J, Lankester AC, Lanza F, Montoto S, Nagler A, Peffault de Latour R, Snowden JA, Styczynski J, Yakoub-Agha I, Kröger N, Mohty M. Indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2019. Bone Marrow Transplant 2019; 54:1525-1552. [PMID: 30953028 DOI: 10.1038/s41409-019-0516-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/20/2022]
Abstract
This is the seventh special EBMT report on the indications for haematopoietic stem cell transplantation for haematological diseases, solid tumours and immune disorders. Our aim is to provide general guidance on transplant indications according to prevailing clinical practice in EBMT countries and centres. In order to inform patient decisions, these recommendations must be considered together with the risk of the disease, the risk of the transplant procedure and the results of non-transplant strategies. In over two decades since the first report, the EBMT indications manuscripts have incorporated changes in transplant practice coming from scientific and technical developments in the field. In this same period, the establishment of JACIE accreditation has promoted high quality and led to improved outcomes of patient and donor care and laboratory performance in transplantation and cellular therapy. An updated report with operating definitions, revised indications and an additional set of data with overall survival at 1 year and non-relapse mortality at day 100 after transplant in the commonest standard-of-care indications is presented. Additional efforts are currently underway to enable EBMT member centres to benchmark their risk-adapted outcomes as part of the Registry upgrade Project 2020 against national and/or international outcome data.
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Affiliation(s)
- Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda - Universidad Autónoma de Madrid, Madrid, Spain.
| | - Myriam Labopin
- EBMT Paris Study Office, Hopital Saint Antoine, Paris, France
| | - Peter Bader
- Goethe University Hospital, Frankfurt/Main, Germany
| | | | - Chiara Bonini
- Vita-Salute San Raffaele University & Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Christian Chabannon
- Institut Paoli Calmettes & Centre d'Investigations Cliniques en Biothérapies, Marseille, France
| | | | - Peter Dreger
- Medizinische Klinik V, Universität Heidelberg, Heidelberg, Germany
| | - Carlo Dufour
- Giannina Gaslini Children's Hospital, Genoa, Italy
| | | | - Jürgen Kuball
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arjan C Lankester
- Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Arnon Nagler
- Chaim Sheva Medical Center, Tel-Hashomer, Israel
| | | | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | | | | | - Mohamad Mohty
- Hopital Saint Antoine, Sorbonne Université, Paris, France
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Puła B, Salomon-Perzyński A, Prochorec-Sobieszek M, Jamroziak K. Immunochemotherapy for Richter syndrome: current insights. Immunotargets Ther 2019; 8:1-14. [PMID: 30788335 PMCID: PMC6368420 DOI: 10.2147/itt.s167456] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Richter syndrome (RS) is recognized as the development of a secondary and aggressive lymphoma during the clinical course of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Most of such histological transformations are from RS to diffuse large B-cell lymphoma (DLBCL-RS, 90%) and Hodgkin’s lymphoma (HL-RS, 10%). Histopathological examination is a prerequisite for diagnosis. It is crucial to assess the relationship between the RS clone and the underlying CLL/SLL because clonally related DLBCL-RS has a poor outcome, while clonally unrelated cases have a prognosis similar to de novo DLBCL. An anti-CD20 antibody-based immunochemotherapy is hitherto the frontline treatment of choice for DLBCL-RS; nonetheless, the results are unsatisfactory. Allogeneic stem cell transplantation should be offered to younger and fit patients as a consolidative treatment; however, the majority of the patients may not be qualified for this procedure. The HL-RS transformation has better outcomes than those of DLBCL-RS and can effectively be treated by the adriamycin, bleomycin, vinblastine, and dacarbazine regimen. Although novel agents are currently being investigated for RS, immunochemotherapy nevertheless remains a standard treatment for DLBCL-RS.
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Affiliation(s)
- Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,
| | | | - Monika Prochorec-Sobieszek
- Department of Diagnostic Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.,Department of Pathology and Laboratory Medicine, Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | - Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,
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54
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Allan JN, Furman RR. Current trends in the management of Richter's syndrome. Int J Hematol Oncol 2019; 7:IJH09. [PMID: 30651968 PMCID: PMC6331753 DOI: 10.2217/ijh-2018-0010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/21/2018] [Indexed: 12/16/2022] Open
Abstract
Richter's syndrome (RS) is a life-threatening complication of chronic lymphocytic leukemia (CLL). While previous research has increased our knowledge on the distinct evolutionary patterns of RS and provided a deeper understanding of the risk factors and molecular events predisposing to transformation, there remain few targetable aberrations and treatment is largely ineffective. The ability to obtain deeper remissions, without selecting for deletion 17p, by using novel B-cell receptor (BCR) antagonists and bcl2 inhibition might lead to a decrease in the incidence of RS, but these agents have done little to significantly change outcomes when incorporated into treatment regimens for RS. In this review we highlight the current landscape of molecular lesions specific to RS, review the data on historical treatment options, and look to the horizon for potential opportunities in the future.
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Affiliation(s)
- John N Allan
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Richard R Furman
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
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Ding W. Richter transformation in the era of novel agents. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:256-263. [PMID: 30504319 PMCID: PMC6245983 DOI: 10.1182/asheducation-2018.1.256] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Recent approvals of several oral targeted agents have revolutionized chronic lymphocytic leukemia (CLL) therapy. However, CLL patients continue to progress; particularly, 4% to 20% of previously treated CLL patients undergo transformation into high-grade lymphoma. Richter transformation is defined as a transformation of CLL into aggressive lymphoma, most commonly diffuse large B-cell lymphoma. These patients typically have poor response to traditional chemotherapy used to treat de novo diffuse large B-cell lymphoma and similar or shorter overall survival (median 3-11 months) in the era of novel agents. Here, I review the contemporary literature on Richter transformation, particularly in the context of novel agents used in CLL, and discuss the management approach for these patients.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Survival Rate
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Affiliation(s)
- Wei Ding
- Chronic Lymphocytic Leukemia Group, Division of Hematology, Mayo Clinic, Rochester, MN
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Parikh SA. Chronic lymphocytic leukemia treatment algorithm 2018. Blood Cancer J 2018; 8:93. [PMID: 30283014 PMCID: PMC6170426 DOI: 10.1038/s41408-018-0131-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 08/22/2018] [Accepted: 09/17/2018] [Indexed: 11/08/2022] Open
Abstract
The treatment landscape for patients with chronic lymphocytic leukemia (CLL) has changed considerably with the introduction of very effective oral targeted therapies (such as ibrutinib, idelalisib, and venetoclax), and next-generation anti-CD20 monoclonal antibodies (such as obinutuzumab). These agents lead to improved outcomes in CLL, even among patients with high-risk features, such as del17p13 or TP53 mutation and unmutated immunoglobulin heavy chain (IGHV) genes. Each of these treatments is associated with a unique toxicity profile; in the absence of randomized data, the choice of one type of treatment over another depends on the co-morbidities of the patient. Chemoimmunotherapy still plays an important role in the management of previously untreated CLL patients, particularly among young fit patients who have standard risk FISH profile and mutated IGHV genes. Richter's transformation of CLL remains a difficult complication to treat, although therapy with programmed death 1 inhibitors such as pembrolizumab and nivolumab has shown impressive responses in a subset of patients. Our ability to risk stratify CLL patients continues to evolve; the CLL-International Prognostic Index (CLL-IPI) is the best validated tool in predicting time to first therapy among previously untreated patients. This review summarizes the current approach to risk stratification and management of CLL patients.
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MESH Headings
- Algorithms
- Biomarkers, Tumor
- Combined Modality Therapy
- Disease Management
- Disease Progression
- Disease Susceptibility
- Drug Resistance, Neoplasm
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Practice Guidelines as Topic
- Prognosis
- Recurrence
- Treatment Outcome
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57
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Xu L, Song JC, Sun XH, Gao ZF, Lv L, Zhu J. Richter's syndrome of the central nervous system diagnosed concurrently with chronic lymphocytic leukaemia: A case report and literature review. Medicine (Baltimore) 2018; 97:e12701. [PMID: 30313065 PMCID: PMC6203471 DOI: 10.1097/md.0000000000012701] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Central nervous system (CNS) infiltration of Richter's syndrome (RS) is rare and only a few cases were discussed. Of these published cases, either they were accompanied with lymph node involvement or with a history of chronic lymphocytic leukemia (CLL). To our knowledge, this is the first published case of RS of the brain and meninges diagnosed concurrently with CLL in the absence of any evidence of lymphoma outside of the CNS. PATIENT CONCERNS A 67-year-old female presented with slurred speech, headache, and left-sided hemiparesis. Magnetic resonance imaging of the brain revealed an irregular lesion 30 mm in diameter in the right parietal lobe. The mass was totally removed and pathology revealed diffuse large B-cell lymphoma (DLBCL) of non-germinal center type by Hans' classification. The patient's leukocyte count was 12.1 × 109/L (76.9% lymphocytes), and fluorescence-activated cell sorting (FACS) analysis of blood revealed a clonal B-cell population (36.75% leukocytes) corresponding to the immunological CLL profile (Matutes score of 5/5). Bone marrow (BM) aspiration and biopsy also indicated CLL. The analysis of immunoglobulin heavy chain gene (IGH) and kappa chain gene (IGK) in the patient's BM and CNS tissue indicated that the DLBCL of the brain was derived from the CLL clone. DIAGNOSES RS of the CNS diagnosed concurrently with CLL. INTERVENTIONS The patient received intravenous chemotherapy (6.0 g methotrexate) and intrathecal chemotherapy (10 mg methotrexate, 50 mg cytarabine, 5 mg dexamethasone). OUTCOMES The patient returned to our department with left-sided hemiparesis and headache 2 weeks after the chemotherapy. Repeat MRI showed progression of the brain lesion. Her general condition deteriorated significantly with confusion and high fever, and she died within a few days at only 10 weeks after the onset of symptoms. LESSONS The survival of CNS-RS patients is very poor and and is always complicated with multiple and different genetic alterations. Because of chemotherapy insensitivity, a multidisciplinary treatment including surgery and radiotherapy together with novel agents may be an option to improving patient outcomes.
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MESH Headings
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Central Nervous System/pathology
- Female
- Flow Cytometry
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukocyte Count
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
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Affiliation(s)
- Liye Xu
- Myeloma and Lymphoma Research Center
| | | | - Xiu Hua Sun
- Myeloma and Lymphoma Research Center, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province
| | - Zi Fen Gao
- Department of Pathology, Peking University, Third Hospital, Beijing
| | | | - Jie Zhu
- Flow Cytometry Center, Second Affiliated Hospital of Dalian Medical University, Dalian, China
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58
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Godfrey J, Leukam MJ, Smith SM. An update in treating transformed lymphoma. Best Pract Res Clin Haematol 2018; 31:251-261. [PMID: 30213394 DOI: 10.1016/j.beha.2018.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
Indolent lymphomas typically have a prolonged course and favorable prognosis. Recent data support survival times that can reach several decades, even if periodic treatment is needed to manage symptoms or stabilize disease. However, all indolent lymphomas have the potential to undergo transformation to an aggressive phenotype, clinically characterized by a rapid progression of adenopathy, new-onset constitutional symptoms, or laboratory abnormalities, and the immediate need for therapeutic intervention. The most common scenario is transformation of follicular lymphoma to either diffuse large B-cell lymphoma or high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 translocations; however, other indolent subtypes such as marginal zone lymphoma, lymphoplasmacytic lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukemia, or even nodular lymphocyte predominant Hodgkin lymphoma, can undergo similar histologic transformation. The prognosis of transformed lymphomas has historically been quite poor, but there is ample evidence this is changing in the rituximab era. This article will provide a review of transformed lymphomas with an emphasis on treatment and the nuances of diagnosis and clinical management. Unless otherwise specified, all discussion in this review pertains to transformed follicular lymphoma which is the more common scenario and the subtype with the most robust data. In many cases, this information can be extrapolated and applied to other indolent histologies (i.e. transformed marginal zone lymphoma); however, several other clinical scenarios, such as Richter's transformation and "double hit" transformations, warrant a distinct discussion and will be reviewed separately.
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Affiliation(s)
- James Godfrey
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA
| | - Michael J Leukam
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA
| | - Sonali M Smith
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA.
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Abstract
AbstractRichter syndrome (RS) is the development of an aggressive lymphoma in patients with chronic lymphocytic leukemia (CLL). Two pathologic variants of RS are recognized: namely, the diffuse large B-cell lymphoma (DLBCL) variant and the rare Hodgkin lymphoma (HL) variant. Histologic documentation is mandatory to diagnose RS. The clinical suspicion of RS should be based on clinical signs and symptoms. Differential diagnosis between CLL progression and RS and choice of the biopsy site may take advantage of positron emission tomography/computed tomography. Molecular lesions of regulators of proliferation (CDKN2A, NOTCH1, MYC) and apoptosis (TP53) overall associate with ∼90% of DLBCL-type RS, whereas the biology of the HL-type RS is largely unknown. The prognosis of the DLBCL-type RS is unfavorable; the outcome of HL-type RS appears to be better. The most important RS prognostic factor is the clonal relationship between the CLL and the aggressive lymphoma clones, with clonally unrelated RS having a better prognosis. Rituximab-containing combination chemotherapy for DLBCL is the most widely used treatment in DLBCL-type RS. Fit patients who respond to induction therapy should be offered stem cell transplantation (SCT) to prolong survival. Adriamycin, bleomycin, vinblastine, and dacarbazine is the preferred regimen for the HL-type RS, and SCT consolidation is less used in this condition.
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Alderuccio JP, Mackrides N, Chapman JR, Vega F, Lossos IS. Rapid complete response to blinatumomab as a successful bridge to allogeneic stem cell transplantation in a case of refractory Richter syndrome. Leuk Lymphoma 2018; 60:230-233. [DOI: 10.1080/10428194.2018.1461862] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Juan Pablo Alderuccio
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nicholas Mackrides
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jennifer R. Chapman
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Francisco Vega
- Department of Pathology and Laboratory Medicine, Division of Hematopathology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Izidore S. Lossos
- Department of Medicine, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Molecular and Cellular Pharmacology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Gauthier J, Chantepie S, Bouabdallah K, Jost E, Nguyen S, Gac AC, Damaj G, Duléry R, Michallet M, Delage J, Lewalle P, Morschhauser F, Salles G, Yakoub-Agha I, Cornillon J. [Allogeneic haematopoietic cell transplantation for indolent lymphomas: Guidelines from the Francophone Society Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]. Bull Cancer 2017; 104:S121-S130. [PMID: 29173973 DOI: 10.1016/j.bulcan.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/01/2017] [Indexed: 10/18/2022]
Abstract
Despite great improvements in the outcome of patients with lymphoma, some may still relapse or present with primary refractory disease. In these situations, allogeneic hematopoietic cell transplantation is a potentially curative option, this is true particularly the case of relapse after autologous stem cell transplantation. Recently, novel agents such as anti-PD1 and BTK inhibitors have started to challenge the use of allogeneic hematopoietic cell transplantation for relapsed or refractory lymphoma. During the 2016 annual workshop of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), we performed a comprehensive review of the literature published in the last 10 years and established guidelines to clarify the indications and transplant modalities in this setting. This paper specifically reports on our conclusions regarding indolent lymphomas, mainly follicular lymphoma and chronic lymphocytic leukemia.
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Affiliation(s)
- Jordan Gauthier
- CHRU de Lille, pôle spécialités médicales et gérontologie, service des maladies du sang, secteur allogreffe de cellules souches hématopoïétiques, 59037 Lille, France; Université de Lille, UFR médecine, 59000 Lille, France
| | - Sylvain Chantepie
- AP-HP, hôpital La Pitié-Salpêtrière, service d'hématologie, 75013 Paris, France
| | | | - Edgar Jost
- Universitätsklinikum Aachen, Klinik für Onkologie, Hämatologie und Stammzelltransplantation, Aachen, Allemagne
| | | | - Anne-Claire Gac
- AP-HP, hôpital La Pitié-Salpêtrière, service d'hématologie, 75013 Paris, France
| | - Gandhi Damaj
- AP-HP, hôpital La Pitié-Salpêtrière, service d'hématologie, 75013 Paris, France
| | - Rémy Duléry
- AP-HP, hôpital Saint-Antoine, service d'hématologie, 75012 Paris, France
| | | | - Jérémy Delage
- CHU de Montpellier, service d'hématologie, 34295 Montpellier, France
| | - Philippe Lewalle
- Université libre de Bruxelles, institut Jules-Bordet, service d'hématologie, Bruxelles, Belgique
| | - Franck Morschhauser
- CHRU de Lille, pôle spécialités médicales et gérontologie, service des maladies du sang, secteur allogreffe de cellules souches hématopoïétiques, 59037 Lille, France; Université de Lille, UFR médecine, 59000 Lille, France
| | - Gilles Salles
- CHU de Lyon, service d'hématologie, 69310 Pierre-Bénite, France
| | - Ibrahim Yakoub-Agha
- CHRU de Lille, pôle spécialités médicales et gérontologie, service des maladies du sang, secteur allogreffe de cellules souches hématopoïétiques, 59037 Lille, France; CHU de Lille, université de Lille2, LIRIC Inserm U995, 59000 Lille, France
| | - Jérôme Cornillon
- Institut de cancérologie Lucien-Neuwirth, département d'hématologie clinique, 42271 Saint-Priest-en-Jarez, France.
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63
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Mina A, Sandoval Sus J, Sleiman E, Pinilla-Ibarz J, Awan FT, Kharfan-Dabaja MA. Using prognostic models in CLL to personalize approach to clinical care: Are we there yet? Blood Rev 2017; 32:159-166. [PMID: 29122300 DOI: 10.1016/j.blre.2017.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/14/2017] [Accepted: 10/27/2017] [Indexed: 01/14/2023]
Abstract
Four decades ago, two staging systems were developed to help stratify CLL into different prognostic categories. These systems, the Rai and the Binet staging, depended entirely on abnormal exam findings and evidence of anemia and thrombocytopenia. Better understanding of biologic, genetic, and molecular characteristics of CLL have contributed to better appreciating its clinical heterogeneity. New prognostic models, the GCLLSG prognostic index and the CLL-IPI, emerged. They incorporate biologic and genetic information related to CLL and are capable of predicting survival outcomes and cases anticipated to need therapy earlier in the disease course. Accordingly, these newer models are helping develop better informed surveillance strategies and ultimately tailor treatment intensity according to presence (or lack thereof) of certain prognostic markers. This represents a step towards personalizing care of CLL patients. We anticipate that as more prognostic factors continue to be identified, the GCLLSG prognostic index and CLL-IPI models will undergo further revisions.
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Affiliation(s)
- Alain Mina
- Dept. of Internal Medicine, Kansas University Medical Ctr, Kansas City, KS, USA
| | | | - Elsa Sleiman
- Faculty of Medicine, American Univ. of Beirut, Beirut, Lebanon
| | - Javier Pinilla-Ibarz
- Dept. of Malignant Hematology, Moffitt Cancer Ctr, Tampa, FL, USA; Department of Oncologic Sciences, Moffitt Cancer Ctr, Univ. of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Farrukh T Awan
- Div. of Hematology, Dept. of Internal Medicine, The Ohio State Univ. Comprehensive Cancer Ctr, Columbus, OH, USA
| | - Mohamed A Kharfan-Dabaja
- Department of Oncologic Sciences, Moffitt Cancer Ctr, Univ. of South Florida Morsani College of Medicine, Tampa, FL, USA; Dept. of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Ctr, Tampa, FL, USA.
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64
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Khan M, Siddiqi R, Thompson PA. Approach to Richter transformation of chronic lymphocytic leukemia in the era of novel therapies. Ann Hematol 2017; 97:1-15. [DOI: 10.1007/s00277-017-3149-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 10/03/2017] [Indexed: 12/22/2022]
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Kharfan-Dabaja MA, Kumar A, Stingo FE, Khimani F, Hussaini M, Ayala E, Nishihori T, Shah B, Locke FL, Pinilla-Ibarz J, Chavez JC. Allogeneic Hematopoietic Cell Transplantation for Richter Syndrome: A Single-Center Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 18:e35-e39. [PMID: 29126867 DOI: 10.1016/j.clml.2017.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 09/19/2017] [Accepted: 10/03/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent studies have shown dismal outcomes when chronic lymphocytic leukemia progresses to Richter syndrome after patients receive ibrutinib, with a median overall survival ranging from 2.6 to 3.5 months. Published data on efficacy of allogeneic hematopoietic cell transplantation in Richter syndrome are limited to single-center case series and registry data. PATIENTS AND METHODS We evaluated the efficacy of allogeneic transplantation in 10 patients, median age of 63 (range, 50-74) years, allografted at a median of 5 (range, 4-25) months from diagnosis of Richter syndrome. All showed an objective response to therapy before transplantation (first complete remission = 7 [70%], first partial response = 2 [20%], second partial response = 1 [10%]). Most received a myeloablative conditioning regimen (n = 7, 70%). Filgrastim-mobilized peripheral blood stem cells was the preferred cell source (n = 10, 100%). RESULTS Median follow-up of surviving patients was 46 (range, 15-82) months. The 4-year overall survival was 50% (95% confidence interval [CI], 19%-81%). Nonrelapse mortality at 1 year and 4 years post-transplantation were 40% (95% CI, 19%-85%) for both time points. The 4-year incidence of relapse/progression was 10% (95% CI, 2%-64%). CONCLUSION Allogeneic hematopoietic cell transplantation is an effective treatment for patients with Richter syndrome who show an objective response before allografting. Patients must be referred to transplant centers as soon as the diagnosis is confirmed to evaluate candidacy for the procedure and identify a suitable donor in a timely manner.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL.
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Facundo E Stingo
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | - Farhad Khimani
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Mohammad Hussaini
- Department of Hematopathology and Laboratory Medicine, Moffitt Cancer Center, Tampa, FL
| | - Ernesto Ayala
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Bijal Shah
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | - Frederick L Locke
- Department of Blood and Marrow Transplantation and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | | | - Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
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Master S, Leary C, Takalkar A, Coltelingam J, Mansour R, Mills GM, Koshy N. Successful Treatment of Richter Transformation with Ibrutinib in a Patient with Chronic Lymphocytic Leukemia following Allogeneic Hematopoietic Stem Cell Transplant. Case Rep Oncol 2017; 10:534-541. [PMID: 28690529 PMCID: PMC5498945 DOI: 10.1159/000477338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 12/23/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) who progress to Richter transformation (RT) have a poor prognosis. Multi-agent chemotherapy regimens do not have good response rates. There are few case reports on the use of ibrutinib in RT. Here, we present a patient who was heavily pretreated for CLL, including allogeneic stem cell transplant, and progressed to RT. She had a mixed response to multi-agent chemotherapy and was started on ibrutinib. She had a complete response for 16 months on single-agent ibrutinib with minimal toxicity.
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Affiliation(s)
- Samip Master
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Cheri Leary
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Amol Takalkar
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - James Coltelingam
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Richard Mansour
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Glenn M Mills
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nebu Koshy
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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67
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Eyre TA, Schuh A. An update for Richter syndrome - new directions and developments. Br J Haematol 2017; 178:508-520. [DOI: 10.1111/bjh.14700] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Toby A. Eyre
- Department of Haematology; Cancer and Haematology Centre; Oxford University Hospitals NHS Trust; Oxford UK
- Early Phase Clinical Trial Unit; Oxford University Hospitals NHS Foundation Trust; Churchill Hospital; Oxford UK
| | - Anna Schuh
- Department of Haematology; Cancer and Haematology Centre; Oxford University Hospitals NHS Trust; Oxford UK
- Early Phase Clinical Trial Unit; Oxford University Hospitals NHS Foundation Trust; Churchill Hospital; Oxford UK
- NIHR BRC Oxford Molecular Diagnostic Centre; Oxford University Hospitals NHS Foundation Trust; Oxford UK
- Department of Oncology; University of Oxford; Oxford UK
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Abstract
The term Richter syndrome (RS) indicates the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma. RS is a rare complication with an aggressive clinical course, bearing an unfavorable prognosis. In the majority of cases, CLL transforms into RS as diffuse large B cell lymphoma (DLBCL), and a clonal relation between the two processes can be found. However, clonally unrelated RS can occur and transformations to other histologies beside DLBCL have been described. Recent data have shed some light on genetic characteristics that can influence and drive the transformation from CLL to RS. This molecular information has not been translated yet into significant treatment advances, and currently the therapy regimens for RS continue to rely on intensive chemotherapy combinations followed by stem cell transplant in suitable candidates. Based on the rapid pace of discoveries in the field of hematological malignancies and on the recent revolution in the therapeutic landscape for CLL and B cell lymphomas, new therapeutic options for RS might be available in the upcoming years.
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Affiliation(s)
- Candida Vitale
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Yun S, Vincelette ND, Abraham I, Puvvada S, Anwer F. Outcome Comparison of Allogeneic versus Autologous Stem Cell Transplantation in Transformed Low-Grade Lymphoid Malignancies: A Systematic Review and Pooled Analysis of Comparative Studies. Acta Haematol 2016; 136:244-255. [PMID: 27802434 DOI: 10.1159/000449031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 08/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Some patients with low-grade lymphoid malignancies develop transformed disease, requiring stem cell transplantation (SCT). SCT outcomes in transformed low-grade lymphoid malignancies may differ from those of nontransformed disease or other aggressive non-Hodgkin lymphomas. We conducted a pooled analysis of the clinical outcomes of allogeneic versus high-dose therapy (HDT) with autologous SCT in adult patients with transformed low-grade lymphoid malignancies. METHODS A PubMed, EMBASE, and Cochrane search yielded 4 comparative studies reporting allogeneic versus HDT with autologous SCT outcomes in adults (age ≥18) with transformed low-grade lymphoid malignancies, including follicular, chronic/small lymphocytic, and marginal zone lymphoma. Risk ratio (RR) and 95% CI were calculated using random-effects models. RESULTS Rates for overall survival (OS) were 51.0 versus 69.5% (RR = 1.55, 95% CI 1.19-2.02, p = 0.001), rates of relapse were 37.3 versus 35.3% (RR = 1.04, 95% CI 0.70-1.55, p = 0.84), and rates of transplant-related mortality (TRM) were 33.3 versus 7.2% (RR = 4.52, 95% CI 2.75-7.43, p < 0.00001) for allogeneic versus autologous SCT. Previous rituximab treatment, reduced intensity conditioning regimen prior to SCT, or original pathology had no prognostic impact. CONCLUSION HDT followed by autologous SCT was associated with lower TRM and a better OS, but there was no difference in relapse versus allogeneic SCT. Autologous SCT may be the better therapeutic option, considering the second chance of allogeneic SCT in the case of relapse.
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Affiliation(s)
- Seongseok Yun
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, Fla., USA
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Soilleux EJ, Wotherspoon A, Eyre TA, Clifford R, Cabes M, Schuh AH. Diagnostic dilemmas of high-grade transformation (Richter's syndrome) of chronic lymphocytic leukaemia: results of the phase II National Cancer Research Institute CHOP-OR clinical trial specialist haemato-pathology central review. Histopathology 2016; 69:1066-1076. [DOI: 10.1111/his.13024] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/26/2016] [Indexed: 01/24/2023]
Affiliation(s)
- Elizabeth J Soilleux
- Nuffield Division of Clinical Laboratory Sciences; Radcliffe Department of Medicine; University of Oxford; John Radcliffe Hospital; Oxford UK
| | | | - Toby A Eyre
- Department of Haematology; Oxford University Hospitals NHS Trust; Churchill Hospital; Oxford UK
- Early Phase Clinical Trial Unit; Oxford University Hospitals NHS Trust; Churchill Hospital; Oxford UK
| | - Ruth Clifford
- Department of Haematology; Oxford University Hospitals NHS Trust; Churchill Hospital; Oxford UK
| | - Maite Cabes
- NIHR BRC Oxford Molecular Diagnostic Centre; Oxford University Hospitals NHS Trust; John Radcliffe Hospital; Oxford UK
| | - Anna H Schuh
- Department of Haematology; Oxford University Hospitals NHS Trust; Churchill Hospital; Oxford UK
- NIHR BRC Oxford Molecular Diagnostic Centre; Oxford University Hospitals NHS Trust; John Radcliffe Hospital; Oxford UK
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71
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Ayers EC, Mato AR. Richter's Transformation in the Era of Kinase Inhibitor Therapy: A Review. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 17:1-6. [PMID: 27707629 DOI: 10.1016/j.clml.2016.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/19/2016] [Accepted: 08/26/2016] [Indexed: 12/16/2022]
Abstract
Richter's transformation (RT) is the transformation of chronic lymphocytic leukemia (CLL) into rapidly progressive B-cell lymphoma. This disease has long been recognized as a difficult-to-treat illness with poor survival outcomes. Although the incidence of RT has been well documented in previous studies, less is understood in the era of novel therapeutics, such as kinase inhibitors (KIs). The present review discusses the current risk factors, incidence, and outcomes of patients with RT in the modern era of KI therapy. Although the outcomes remain poor for RT patients after KI therapy, the most up-to-date studies have shown no increased incidence of RT in this patient population. Additionally, the present review reports the outcomes from the most recent data on novel therapies under investigation for patients with RT.
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Affiliation(s)
- Emily C Ayers
- Center for CLL, Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA
| | - Anthony R Mato
- Center for CLL, Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA.
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El-Asmar J, Kharfan-Dabaja MA. Hematopoietic Cell Transplantation for Richter Syndrome. Biol Blood Marrow Transplant 2016; 22:1938-1944. [PMID: 27375122 DOI: 10.1016/j.bbmt.2016.06.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 06/28/2016] [Indexed: 01/11/2023]
Abstract
Treatment combining chemotherapy with immunotherapy as well as novel targeted therapies have shown limited efficacy in Richter syndrome. Overall response rates after chemoimmunotherapy range from 43% to 67%, but remissions are generally short-lived. In chronic lymphocytic leukemia (CLL), allogeneic hematopoietic cell transplantation (all-HCT) is considered a potentially curative treatment modality, yielding 3-year overall survival rates exceeding 50% and a plateau in survival curves. In Richter syndrome, efficacy of allo-HCT depends on demonstrating an objective response (complete remission or partial response) before allografting, with resulting 3-year survival rates of 41% to 75%. On the other hand, the efficacy of autologous HCT is limited, especially when considering that patients autografted for Richter syndrome might relapse with CLL in 35% of cases. Notwithstanding the scarcity of published data, we recommend that patients with Richter syndrome should be referred to transplant centers as soon as the diagnosis is confirmed to evaluate their candidacy for allo-HCT. Establishing a clonal relationship to CLL is important considering the more aggressive disease course in clonally related Richter syndrome. Moreover, achievement of a complete remission or partial response to salvage therapy must be a prerequisite before moving forward with allografting for Richter syndrome. Patients who fail to demonstrate an objective response to salvage therapy should be considered for enrollment in clinical trials.
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Affiliation(s)
- Jessica El-Asmar
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida; Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Florida.
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74
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Richter's syndrome: Novel and promising therapeutic alternatives. Best Pract Res Clin Haematol 2016; 29:30-39. [DOI: 10.1016/j.beha.2016.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 06/29/2016] [Accepted: 08/04/2016] [Indexed: 12/20/2022]
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75
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Abstract
Richter syndrome (RS) is the development of an aggressive lymphoma in patients with a previous or concomitant diagnosis of chronic lymphocytic leukemia (CLL). The incidence rate RS is ~0.5% per year of observation. Two biomarkers (NOTCH1 mutations and subset 8 configuration of the B-cell receptor) may help identifying CLL patients at risk of RS to be considered for close monitoring and a careful biopsy policy. In the presence of clinical features suspicious of RS, diagnosis of transformation and choice of the site of biopsy may take advantage of fluorine 18 fluorodeoxyglucose ((18)FDG) positron emission tomography (PET)/computed tomography (CT). Molecular lesions of regulators of tumor suppression (TP53), cell cycle (CDKN2A), and cell proliferation (NOTCH1, MYC) overall account for ~90% of RS and may be responsible for the aggressive clinical phenotype observed in this disease because of the combined effect of chemoresistance and rapid disease kinetics. The prognosis of RS is generally highly unfavorable. However, the pattern of survival is not homogeneous and the most important prognostic factor is the clonal relationship between the CLL and the aggressive lymphoma clones. Rituximab-containing polychemotherapy represents the backbone for induction treatment in RS. Younger patients who respond to induction therapy should be offered stem cell transplant (SCT) to prolong survival.
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Affiliation(s)
- Davide Rossi
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
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76
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Abstract
Abstract
Histologic transformation (HT) is a frequent event in the clinical course of patients with indolent lymphoma. Most of the available data in the literature comes from studies on transformation of follicular lymphoma (FL), as this is the most common indolent lymphoma; however, HT is also well documented following small lymphocytic lymphoma/chronic lymphocytic leukaemia (SLL/CLL), lymphoplasmacytic lymphoma (LPL), or marginal zone lymphoma (MZL), amongst other types of lymphoma, albeit most of the studies on transformation in these subtypes are case reports or short series. The outcome of patients with HT has traditionally been considered dismal with a median overall survival (OS) of around 1 year in most of the published studies. This prompted many authors to include stem cell transplant (SCT) as part of the treatment strategy for young and fit patients with HT. However, recent articles suggest that the outcome of patients with transformed lymphoma might be improving, questioning the need for such intensive therapies. The management of patients with HT is challenged by the heterogeneity of the population in terms of previous number and type of therapy lines and from their exclusion from prospective clinical trials. This review will examine whether the advent of new therapies has impacted on the prognosis of HT and on current treatment strategies.
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78
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Rozovski U, Benjamini O, Jain P, Thompson PA, Wierda WG, O'Brien S, Burger JA, Ferrajoli A, Faderl S, Shpall E, Hosing C, Khouri IF, Champlin R, Keating MJ, Estrov Z. Outcomes of Patients With Chronic Lymphocytic Leukemia and Richter's Transformation After Transplantation Failure. J Clin Oncol 2015; 33:1557-63. [PMID: 25847930 DOI: 10.1200/jco.2014.58.6750] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Allogeneic stem-cell transplantation (SCT) induces long-term remission in a fraction of patients with high-risk chronic lymphocytic leukemia (CLL) or Richter's transformation (RT). Our purpose was to determine the outcomes of patients whose disease progressed after allogeneic SCT. PATIENTS AND METHODS We retrospectively analyzed the outcomes of 72 patients (52 with CLL and 20 with RT) who underwent allogeneic SCT between 1998 and 2011 and had documented progression after transplantation. Twenty-two (31%) never had a response, and 50 (69%) had a response but experienced relapse after a median of 7 months (range, 2 to 85 months). Forty-eight patients who were receiving or were candidates to receive post-SCT cell-based therapies were not included in this analysis. RESULTS The median age at time of transplantation was 58 years (range, 30 to 72 years). Sixty-two patients (86%) received more than two treatment regimens and 37 (51%) received more than three treatment regimens before SCT. Sixty-six patients (92%) had active disease at the time of transplantation. The 2- and 5-year survival rates were 67% and 38% (patients with CLL) and 36% and 0% (patients with RT). The patients who developed acute or chronic graft-versus-host disease had a longer overall survival (OS; P = .05). In a multivariable analysis, RT or low hemoglobin at the time of SCT predicted shorter OS. Chronic graft-versus-host disease and an initial response to SCT predicted longer OS. CONCLUSION Patients with CLL in whom allogeneic SCT fails may have a response to and benefit from salvage therapies, and their prognosis is relatively good.
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Affiliation(s)
- Uri Rozovski
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ohad Benjamini
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Preetesh Jain
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip A Thompson
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William G Wierda
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O'Brien
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan A Burger
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Stefan Faderl
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Shpall
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Chitra Hosing
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Issa F Khouri
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Richard Champlin
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael J Keating
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zeev Estrov
- All authors: The University of Texas MD Anderson Cancer Center, Houston, TX.
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Jamroziak K, Tadmor T, Robak T, Polliack A. Richter syndrome in chronic lymphocytic leukemia: updates on biology, clinical features and therapy. Leuk Lymphoma 2015; 56:1949-58. [PMID: 25356923 DOI: 10.3109/10428194.2014.979411] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Richter syndrome (RS) or Richter transformation is the development of secondary aggressive lymphoma in the setting of underlying chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Most frequently CLL transforms into diffuse large B-cell lymphoma (DLBCL) (90%) and rarely (10%) into Hodgkin lymphoma, termed Hodgkin variant of Richter syndrome (HvRS). RS is generally characterized by an aggressive clinical course and poor prognosis. In recent years, major advances have been made in understanding genetic events which relate to the progression of CLL or transformation into RS. Better understanding of the molecular pathways has revealed that RS is not a single homogeneous entity. The majority of cases are clonally related to the original CLL clone, while a minority develop from an unrelated clone. This review summarizes new data relating to the molecular biology and the genetic/epigenetic changes occurring during Richter transformation, and also considers the clinical features and therapy for both DLBCL-RS and Hodgkin variant-RS.
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Affiliation(s)
- Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine , Warsaw , Poland
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80
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Aldoss I, Nademanee A. Allogeneic hematopoietic cell transplantation in non-Hodgkin's lymphomas. Cancer Treat Res 2015; 165:329-344. [PMID: 25655617 DOI: 10.1007/978-3-319-13150-4_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Allogeneic hematopoietic cell transplant (alloHCT) has emerged as a potential curative treatment for advanced non-Hodgkin's lymphoma (NHL), especially for patients with chemorefractory disease, relapsed after prior autologous HCT and those with relapsed lymphoma who failed to collect adequate stem cells for autologous HCT. There are several phase II studies supported the role of alloHCT in low-grade lymphomas, but the data is scarce on the other subtypes of lymphomas. However, retrospective registries studies highlighted the inferior outcomes of alloHCT in aggressive lymphomas, with unacceptable higher relapse rate and non-relapse mortality when compared to low-grade lymphomas. Patients with chemorefractory disease and those with active disease at alloHCT had poor outcome. Therefore, incorporation of new target therapies to induce remission prior to transplant or as a bridge to alloHCT may lead to better outcome of alloHCT in NHL. Furthermore, well design prospective studies of alloHCT in NHL and employment of novel transplant approaches tailored toward specific histological subtype are urgently needed.
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Affiliation(s)
- Ibrahim Aldoss
- City of Hope National Medical Center, Hematology and Hematopoietic Cell Transplantation, 1500 East Duarte Road, Duarte, CA, 91010, USA
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81
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Dreger P, Schetelig J, Andersen N, Corradini P, van Gelder M, Gribben J, Kimby E, Michallet M, Moreno C, Stilgenbauer S, Montserrat E. Managing high-risk CLL during transition to a new treatment era: stem cell transplantation or novel agents? Blood 2014; 124:3841-9. [PMID: 25301705 PMCID: PMC4276025 DOI: 10.1182/blood-2014-07-586826] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/27/2014] [Indexed: 01/01/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been considered as the treatment of choice for patients with high-risk chronic lymphocytic leukemia (HR-CLL; ie, refractory to purine analogs, short response [<24 months] to chemoimmunotherapy, and/or presence of del[17p]/TP53 mutations). Currently, treatment algorithms for HR-CLL are being challenged by the introduction of novel classes of drugs. Among them, BCR signal inhibitors (BCRi) and B-cell lymphoma 2 antagonists (BCL2a) appear particularly promising. As a result of the growing body of favorable outcome data reported for BCRi/BCL2a, uncertainty is emerging on how to advise patients with HR-CLL about indication for and timing of HSCT. This article provides an overview of currently available evidence and theoretical considerations to guide this difficult decision process. Until the risks and benefits of different treatment strategies are settled, all patients with HR-CLL should be considered for treatment with BCRi/BCL2a. For patients who respond to these agents, there are 2 treatment possibilities: (1) performing an HSCT or (2) continuing treatment with the novel drug. Individual disease-specific and transplant-related risk factors, along with patient's preferences, should be taken into account when recommending one of these treatments over the other.
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Affiliation(s)
- Peter Dreger
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Johannes Schetelig
- Department Medicine I, University of Dresden, Dresden, Germany; German Bone Marrow Donor Registry, Tübingen, Germany
| | - Niels Andersen
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Paolo Corradini
- Department Hematology and Pediatric Onco-Hematology, Istituto Nazionale dei Tumori, Milan, Italy
| | - Michel van Gelder
- Department Internal Medicine/Hematology, Maastricht University, Maastricht, The Netherlands
| | - John Gribben
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Eva Kimby
- Department of Medicine/Hematology Unit, Karolinska Institute, Huddinge, Sweden
| | | | - Carol Moreno
- Hospital de la Santa Creu Sant Pau, Barcelona, Spain
| | | | - Emili Montserrat
- Department of Hematology, Hospital Clínic, University of Barcelona, Barcelona, Spain
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82
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Villa D, George A, Seymour JF, Toze CL, Crump M, Lee C, Buckstein R, Stewart DA, MacDonald D, Foley R, Xenocostas A, Sabloff M, Chua N, Couture F, Larouche JF, Cohen S, Savage KJ, Connors JM, Panzarella T, Carney DA, Dickinson M, Kuruvilla J. Favorable Outcomes from Allogeneic and Autologous Stem Cell Transplantation for Patients with Transformed Nonfollicular Indolent Lymphoma. Biol Blood Marrow Transplant 2014; 20:1813-8. [DOI: 10.1016/j.bbmt.2014.07.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
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Parikh SA, Kay NE, Shanafelt TD. How we treat Richter syndrome. Blood 2014; 123:1647-57. [PMID: 24421328 PMCID: PMC3954047 DOI: 10.1182/blood-2013-11-516229] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/07/2014] [Indexed: 01/13/2023] Open
Abstract
Richter syndrome (RS) is defined as the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). RS occurs in approximately 2% to 10% of CLL patients during the course of their disease, with a transformation rate of 0.5% to 1% per year. A combination of germline genetic characteristics, clinical features (eg, advanced Rai stage), biologic (ζ-associated protein-70(+), CD38(+), CD49d(+)) and somatic genetic (del17p13.1 or del11q23.1) characteristics of CLL B cells, and certain CLL therapies are associated with higher risk of RS. Recent studies have also identified the crucial role of CDKN2A loss, TP53 disruption, C-MYC activation, and NOTCH1 mutations in the transformation from CLL to RS. An excisional lymph node biopsy is considered the gold standard for diagnosis of RS; a (18)F-fluorodeoxyglucose positron emission tomography scan can help inform the optimal site for biopsy. Approximately 80% of DLBCL cases in patients with CLL are clonally related to the underlying CLL, and the median survival for these patients is approximately 1 year. In contrast, the remaining 20% of patients have a clonally unrelated DLBCL and have a prognosis similar to that of de novo DLBCL. For patients with clonally related DLBCL, induction therapy with either an anthracycline- or platinum-based regimen is the standard approach. Postremission stem cell transplantation should be considered for appropriate patients. This article summarizes our approach to the clinical management of CLL patients who develop RS.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/pathology
- Combined Modality Therapy
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Middle Aged
- Prognosis
- Stem Cell Transplantation
- Transplantation, Autologous
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Affiliation(s)
- Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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Correlation between FDG/PET, histology, characteristics, and survival in 332 patients with chronic lymphoid leukemia. Blood 2014; 123:2783-90. [PMID: 24615780 DOI: 10.1182/blood-2013-11-536169] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Richter syndrome (RS) is associated with poor outcome. The prognosis of patients with histologically aggressive chronic lymphocytic leukemia (CLL), or HAC, has not been studied. We aimed to correlate 2-deoxy-2-[(18)F]fluoroglucose/positron emission tomography (FDG/PET) data, histological diagnosis, clinical characteristics, and survival in patients with CLL. A total of 332 patients with CLL were histologically classified as: 95 RS, 117 HAC, and 120 histologically indolent CLL (HIC). HAC and RS patients had higher maximum standardized uptake value (SUVmax), more frequent constitutional symptoms, poorer performance status (PS), lower hemoglobin and platelets, and higher lactate dehydrogenase and β-2-microglobulin. An SUVmax ≥10 strongly correlated with mortality (overall survival [OS], 56.7 vs 6.9 months in patients with SUVmax <10 vs ≥10). Survival of patients with RS and HAC was similar among patients with SUVmax <10 or ≥10. SUVmax ≥10, PS ≥2, bulky disease, and age ≥65 were independently associated with shorter OS. In patients undergoing both fine-needle aspiration and biopsy, the former proved diagnostically inadequate in 23%, 29%, and 53% of HIC, HAC, and RS, respectively. FDG/PET is a useful diagnostic tool in patients with CLL and suspected transformation. Patients with HAC show different characteristics and worse prognosis compared with those with HIC. Patients with different CLL phases, but similar SUVmax have similar outcome. Tissue biopsy should be preferred for diagnosing RS.
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Tomblyn MR. Reprint of: A review of cellular therapies for chronic lymphocytic leukemia. Biol Blood Marrow Transplant 2014; 20:S18-S21. [PMID: 24485018 DOI: 10.1016/j.bbmt.2014.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Marcie Riches Tomblyn
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
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A Review of Cellular Therapies for Chronic Lymphocytic Leukemia. Biol Blood Marrow Transplant 2014; 20:164-7. [DOI: 10.1016/j.bbmt.2013.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 11/19/2022]
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Parikh SA, Rabe KG, Call TG, Zent CS, Habermann TM, Ding W, Leis JF, Schwager SM, Hanson CA, Macon WR, Kay NE, Slager SL, Shanafelt TD. Diffuse large B-cell lymphoma (Richter syndrome) in patients with chronic lymphocytic leukaemia (CLL): a cohort study of newly diagnosed patients. Br J Haematol 2013; 162:774-82. [PMID: 23841899 DOI: 10.1111/bjh.12458] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/09/2013] [Indexed: 11/29/2022]
Abstract
Nearly all information about patients with chronic lymphocytic leukaemia (CLL) who develop diffuse large B-cell lymphoma [Richter syndrome (RS)] is derived from retrospective case series or patients treated on clinical trials. We used the Mayo Clinic CLL Database to identify patients with newly diagnosed CLL between January 2000 and July 2011. Individuals who developed biopsy-proven RS during follow-up were identified. After a median follow-up of 4 years, 37/1641 (2·3%) CLL patients developed RS. The rate of RS was approximately 0·5%/year. Risk of RS was associated with advanced Rai stage at diagnosis (P < 0·001), high-risk genetic abnormalitites on fluorescence in situ hybridization (P < 0·0001), unmutated IGHV (P = 0·003), and expression of ZAP70 (P = 0·02) and CD38 (P = 0·001). The rate of RS doubled in patients after treatment for CLL (1%/year). Stereotyped B-cell receptors (odds-ratio = 4·2; P = 0·01) but not IGHV4-39 family usage was associated with increased risk of RS. Treatment with combination of purine analogues and alkylating agents increased the risk of RS three-fold (odds-ratio = 3·26, P = 0·0003). Median survival after RS diagnosis was 2·1 years. The RS prognosis score stratified patients into three risk groups with median survivals of 0·5 years, 2·1 years and not reached. Both underlying characteristics of the CLL clone and subsequent CLL therapy influence the risk of RS. Survival after RS remains poor and new therapies are needed.
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Affiliation(s)
- Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Transformation of chronic lymphocytic leukemia (CLL) to aggressive lymphoma is known as Richter syndrome (RS). In the CLL population considered as a whole, the prevalence of RS development ranges from 2 to 7 %. The most common pathologic phenotype at the time of RS transformation is diffuse large B-cell lymphoma (DLBCL), while, in a small fraction of cases, the transformed phase shows pathologic features mimicking Hodgkin lymphoma. TP53 disruption and MYC activation cooperate as dual hits in driving DLBCL transformation. Two biomarkers (NOTCH1 mutations and usage of the immunoglobulin VH CDR3 subset 8) may help in identifying CLL patients at risk of DLBCL transformation to be considered for close monitoring and a careful biopsy policy. In the presence of clinical features suspicious of RS, diagnosis of transformation and choice of the site of biopsy may take advantage of (18)FDG PET/CT. The prognosis of RS transformation is generally highly unfavorable. However, the pattern of survival is not homogeneous and may be predicted on clinical and biological grounds. RS that are clonally unrelated to the paired CLL phase are biologically and clinically different from clonally related cases, and should be considered, and probably managed, as a de novo DLBCL arising in the context of CLL. Rituximab-containing polychemotherapy represents the backbone for induction treatment in patients with clonally related DLBCL transformation. Younger patients who respond to induction therapy should be offered stem cell transplant to prolong survival.
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Autologous Stem Cell Transplantation for Chronic Lymphocytic Leukemia - Still a Valid Treatment Option, or is the Game Over? Mediterr J Hematol Infect Dis 2012. [PMID: 23205259 PMCID: PMC3507531 DOI: 10.4084/mjhid.2012.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Chemoimmunotherapy with fludarabine, cyclophosphamide, and rituximab (FCR) has been established as the current standard of care for young and fit patients with chronic lymphocytic leukemia (CLL). In the early nineties of the last century, long before the advent of fludarabine or antibody-based strategies, there was realistic hope that myeloablative therapy followed by autologous stem cell transplantation (autoSCT) might be an effective and potentially curative front-line treatment option for suitable patients with CLL. Since then, several prospective trials have disenthralled this hope: although autoSCT can prolong event and progression-free survival if used as part of early front-line treatment, it does not improve overall survival, while it is associated with an increased risk of late adverse events such as secondary malignancies. In addition, autoSCT lacks the potential to overcome the negative impact of biomarkers that confer resistance to chemotherapy or early relapse. The role of autoSCT has also been explored in the context of FCR, and it was demonstrated that its effect is inferior to the currently established optimal treatment regimen. In view of ongoing attempts to improve on FCR, promising clinical activity of new substances even in relapsed/ refractory CLL patients, exciting novel cell therapy approaches and advantages in the understanding of the disease and detection of Minimal Residual Disease (MRD), autoSCT has lost its place as a standard treatment option for CLL.
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