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Optimizing therapy for nodal marginal zone lymphoma. Blood 2016; 127:2064-71. [PMID: 26989202 DOI: 10.1182/blood-2015-12-624296] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 01/27/2016] [Indexed: 12/20/2022] Open
Abstract
Nodal marginal zone lymphoma (NMZL) is a rare form of indolent small B-cell lymphoma which has only been clearly identified in the last 2 decades and which to date remains incurable. Progress in therapeutic management has been slow, largely due to the very small number of patients treated and the heterogeneity of treatments administered; thus, standard-of-care treatment is currently nonspecific for this lymphoma entity. In this review, treatments routinely used to manage adult NMZL patients are presented, principally based on immunochemotherapy (when treatment is needed). Biological research behind the key axes of agents currently under development is described; development of novel agents is heavily based on data from gene profiling and genome-wide sequencing research, uncovering a number of critical deregulated pathways specific to NMZL tumors. These include B-cell receptor, JAK/STAT, NF-κB, NOTCH, and Toll-like receptor signaling pathways, as well as intracellular processes such as the cell cycle, chromatin remodeling, and transcriptional regulation in terms of epigenetic modifiers, histones, or transcriptional co-repressors, along with immune escape via T-cell-mediated tumor surveillance. These pathways are examined in detail and a projection of how the field may evolve in the near future for an efficient personalized treatment approach for NMZL patients is presented.
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Luminari S, Goldaniga M, Cesaretti M, Orsucci L, Tucci A, Pulsoni A, Salvi F, Arcaini L, Carella AM, Tedeschi A, Pinto A, Stelitano C, Baldini L. A phase II study of bendamustine in combination with rituximab as initial treatment for patients with indolent non-follicular non-Hodgkin lymphoma. Leuk Lymphoma 2016; 57:880-7. [PMID: 26379040 DOI: 10.3109/10428194.2015.1091934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this phase 2 study was to determine the activity and safety of six cycles of bendamustine and eight rituximab (RB) as first-line treatment of adult patients with advanced stage non-follicular indolent non-Hodgkin lymphomas (INFL). The primary end-point was the complete response rate (CRR) with expected CRR of 75%. Sixty-nine patients were enrolled; median age was 65 years (45-75), 65% were male, 93% of patients had stage IV disease. Complete and overall response rates were 48% (95% CI = 35.6-60.2) and 86% (CI = 75.0-92.8). The most common grade 3/4 adverse events were neutropenia (43%), thrombocytopenia (7%) and anemia (4%); whereas the rate of febrile neutropenia was very low (3%). At a median follow-up of 22 months (1-43 months), 2-year progression-free survival was 89% (CI = 79-95) and 2-year overall survival was 96% (CI = 87-99). RB combination is active and well tolerated in patients with advanced stage previously untreated INFL.
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Affiliation(s)
- Stefano Luminari
- a Department of Diagnostic , Clinical, and Public Health Medicine, University of Modena and Reggio Emilia , Modena , Italy
| | - Maria Goldaniga
- b Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena , Milano , Italy
| | - Marina Cesaretti
- a Department of Diagnostic , Clinical, and Public Health Medicine, University of Modena and Reggio Emilia , Modena , Italy
| | - Lorella Orsucci
- c Hematology, Città della Salute e della Scienza , Torino , Italy
| | | | | | - Flavia Salvi
- f Azienda ospedaliera nazionale SS. Antonio e Biagio e Cesare Arrigo , Alessandria
| | - Luca Arcaini
- g Department of Hematology Oncology , Fondazione IRCCS Policlinico San Matteo, University of Pavia , Pavia , Italy
| | | | | | - Antonello Pinto
- j UOSC di Ematologia Oncologica, Istituto Nazionale Tumori, Fondazione Pascale, IRCCS , Napoli , Italy
| | - Caterina Stelitano
- k Azienda ospedaliera Bianchi Melacrino Morelli , Reggio Calabria , Italy
| | - Luca Baldini
- b Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena , Milano , Italy
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De Angelis F, Tosti ME, Capria S, Russo E, D'Elia GM, Annechini G, Stefanizzi C, Foà R, Pulsoni A. Risk of secondary hypogammaglobulinaemia after Rituximab and Fludarabine in indolent non-Hodgkin lymphomas: A retrospective cohort study. Leuk Res 2015; 39:1382-8. [PMID: 26547259 DOI: 10.1016/j.leukres.2015.10.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/15/2015] [Accepted: 10/23/2015] [Indexed: 11/28/2022]
Abstract
The occurrence of secondary hypogammaglobulinemia (SH) after chemo-immunotherapy represents a potential side effect in patients with indolent non-Hodgkin lymphomas (iNHL). Few data are available on SH occurring after chemotherapy and/or Rituximab (R). We retrospectively investigated the incidence and the risk factors for SH and infectious complications in patients with iNHL after chemo-immunotherapy. Two hundred and sixty six patients treated between 1993 and 2011 were studied. Patients with a basal hypogammaglobulinemia or a monoclonal component were excluded. The incidence of SH was 2.2×1000 person-years (95% CI 1.6-2.9). Exposure to Fludarabine-based schedules (Fbs)±R was associated with a hazard ratio (HR) of 18.1 (95% CI: 4.3-77.0). Conversely, exposure to CHOP±R or CVP±R was not a risk factor (HR 0.3, 95% CI: 0.1-0.8; HR 0.3, 95% CI: 0.08-1.4, respectively). The role of R was studied comparing cohorts differing only for R; no differences were found comparing R-CHOP/R-CVP versus CHOP/CVP (HR 1.07, 95% CI: 0.38-3.05) and R-Fbs versus Fbs (HR 2.07, 95% CI: 0.62-6.99). Autologous stem cell transplantation (ASCT) is also a risk factor (HR: 5.2, 95% CI 2.1-13.0). SH patients presented a high risk for pneumonia development (HR 7.07 95% CI: 2.68-18.44). We recommend monitoring of serum immunoglobulins in an attempt to reduce the probability of infection after Fbs or ASCT.
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Affiliation(s)
- Federico De Angelis
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy.
| | - Maria Elena Tosti
- National Center for Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health (ISS), Rome, Italy
| | - Saveria Capria
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Eleonora Russo
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Gianna Maria D'Elia
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Giorgia Annechini
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Caterina Stefanizzi
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Alessandro Pulsoni
- Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
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Tarella C, Arcaini L, Baldini L, Barosi G, Billio A, Marchetti M, Rambaldi A, Vitolo U, Zinzani PL, Tura S. Italian Society of Hematology, Italian Society of Experimental Hematology, and Italian Group for Bone Marrow Transplantation Guidelines for the Management of Indolent, Nonfollicular B-Cell Lymphoma (Marginal Zone, Lymphoplasmacytic, and Small Lymphocytic Lymphoma). CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:75-85. [DOI: 10.1016/j.clml.2014.07.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 07/03/2014] [Accepted: 07/08/2014] [Indexed: 12/19/2022]
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Fabbri A, Cencini E, Rigacci L, Bartalucci G, Puccini B, Dottori R, Gozzetti A, Bosi A, Bocchia M. Efficacy and safety of rituximab plus low-dose oral fludarabine and cyclophosphamide as first-line treatment of elderly patients with indolent non-Hodgkin lymphomas. Leuk Lymphoma 2014; 55:781-5. [PMID: 23876098 DOI: 10.3109/10428194.2013.826354] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Indolent non-Hodgkin lymphomas (iNHLs) are B-cell neoplasms for which no consensus is available about optimal first-line therapy. Chemoimmunotherapy with fludarabine, cyclophospamide and rituximab is very effective, but may give severe hematological and non-hematological toxicity at standard doses, especially in elderly patients. In this phase II study, 25 untreated elderly patients with iNHL received rituximab (375 mg/m(2)) plus low-dose oral fludarabine (25 mg/m(2) for 4 consecutive days) and cyclophosphamide (150 mg/m(2) for 4 consecutive days) for four monthly cycles. Twenty-three patients were responsive (92%) and 12 patients achieved a complete remission (48%). Twenty-one patients (84%) were alive, median follow-up was 30 months and median event-free survival (EFS) was not reached. Patients who we previously treated with chemotherapy alone had a shorter EFS (median 20 months). Compliance was good, with mild toxicity. This regimen is effective for elderly patients with iNHL. The addition of rituximab results in long EFS without affecting toxicity.
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Affiliation(s)
- Alberto Fabbri
- Unit of Hematology, University Hospital of Siena , Italy
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Angelopoulou MK, Kalpadakis C, Pangalis GA, Kyrtsonis MC, Vassilakopoulos TP. Nodal marginal zone lymphoma. Leuk Lymphoma 2013; 55:1240-50. [DOI: 10.3109/10428194.2013.840888] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Xu XX, Yan B, Wang ZX, Yu Y, Wu XX, Zhang YZ. Fludarabine-based versus CHOP-like regimens with or without rituximab in patients with previously untreated indolent lymphoma: a retrospective analysis of safety and efficacy. Onco Targets Ther 2013; 6:1385-92. [PMID: 24143112 PMCID: PMC3797259 DOI: 10.2147/ott.s47764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Fludarabine-based regimens and CHOP (doxorubicin, cyclophosphamide, vincristine, prednisone)-like regimens with or without rituximab are the most common treatment modalities for indolent lymphoma. However, there is no clear evidence to date about which chemotherapy regimen should be the proper initial treatment of indolent lymphoma. More recently, the use of fludarabine has raised concerns due to its high number of toxicities, especially hematological toxicity and infectious complications. The present study aimed to retrospectively evaluate both the efficacy and the potential toxicities of the two main regimens (fludarabine-based and CHOP-like regimens) in patients with previously untreated indolent lymphoma. Among a total of 107 patients assessed, 54 patients received fludarabine-based regimens (FLU arm) and 53 received CHOP or CHOPE (doxorubicin, cyclophosphamide, vincristine, prednisone, or plus etoposide) regimens (CHOP arm). The results demonstrated that fludarabine-based regimens could induce significantly improved progression-free survival (PFS) compared with CHOP-like regimens. However, the FLU arm showed overall survival, complete response, and overall response rates similar to those of the CHOP arm. Grade 3–4 neutropenia occurred in 42.6% of the FLU arm and 7.5% of the CHOP arm (P < 0.000). Moreover, the FLU arm also had a higher occurrence of infection than the CHOP arm (27.8% vs 8.5%; P = 0.034). Multi-factor regression of infection revealed that only age (>60 years) and presentation of grade 3–4 myelosuppression were the independent factors to infection, and the FLU arm had significantly higher myelosuppression. In conclusion, the present study revealed that the use of fludarabine-based regimens could induce high rates of myelosuppression over CHOP-like regimens, in spite of significant increases in PFS.
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Affiliation(s)
- Xiao-Xiao Xu
- Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin
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Ferrario A, Pulsoni A, Olivero B, Rossi G, Vitolo U, Tedeschi A, Merli F, Rigacci L, Stelitano C, Goldaniga M, Mannina D, Musto P, Rossi F, Gamba E, Baldini L. Fludarabine, cyclophosphamide, and rituximab in patients with advanced, untreated, indolent B-cell nonfollicular lymphomas: phase 2 study of the Italian Lymphoma Foundation. Cancer 2011; 118:3954-61. [PMID: 22179904 DOI: 10.1002/cncr.26708] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 10/24/2011] [Accepted: 10/31/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Indolent nonfollicular non-Hodgkin B-cell lymphomas (INFLs) are clonal mature B-cell proliferations for which treatment has not been defined to date. METHODS In this phase 2 study of patients with advanced INFL, the authors evaluated the efficacy and safety of first-line rituximab, fludarabine, and cyclophosphamide (FCR) as induction immunochemotherapy (rituximab 375 mg/m(2) intravenously on day 1 of each cycle and on days 1 and 14 of cycles 4 and 5; fludarabine 25 mg/m(2) intravenously on days 2-4, cyclophosphamide 250 mg/m(2) intravenously on Days 2-4) every 28 days for 6 cycles followed by a maintenance phase with 4 infusions of rituximab (375 mg/m(2) intravenously on day 1) every 2 months for responders. RESULTS Forty-seven patients were enrolled. Among 46 evaluable patients (28 men; median age, 59 years), 19 were diagnosed with lymphoplasmacytic lymphoma, 21 were diagnosed with small lymphocytic lymphoma, and 6 were diagnosed with nodal marginal zone lymphoma. The overall response rate after maintenance was 89.1% with a 67.4% complete remission (CR) rate (CR/unconfirmed CR) and a 21.7% partial response rate. After a median follow-up of 40.9 months, the failure-free survival and progression-free survival rates both were 90.1%, and the overall survival rate was 97.4%. The main toxicity was hematologic, and related grade 3 and 4 neutropenia was observed in 55.3% of patients. CONCLUSIONS FCR induction therapy followed by a short maintenance phase is a highly effective regimen with acceptable toxicity.
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Affiliation(s)
- Andrea Ferrario
- Hematology Unit 1, IRCCS Foundation, Ca Granda Hospital "Maggiore Policlinico", University of Milan, Milan, Italy
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Ahn JS, Yang DH, Jung SH, Bae SY, Tran HTT, Park HC, Kim HN, Kim YK, Kim HJ, Lee JJ. Fludarabine-containing chemotherapy for patients with previously untreated low-grade non-Hodgkin's lymphoma. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:180-5. [PMID: 22065973 PMCID: PMC3208201 DOI: 10.5045/kjh.2011.46.3.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 08/17/2011] [Accepted: 08/23/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The clinical efficacy and safety of fludarabine combination chemotherapy was investigated for the treatment of previously untreated patients with low-grade (NHL). METHODS Twenty-five patients who were newly diagnosed as low-grade NHL were treated with fludarabine combination chemotherapy. Fludarabine combination regimens consisted of fludarabine, mitoxantrone and dexamethasone or fludarabine, cyclophosphamide and mitoxantrone with or without rituximab and repeated every 4 weeks. RESULTS The median age was 60 years (range, 35-77 years), with 13 of 25 patients (52%) ≥60 years of age. Seven of 25 patients (28%) with an intermediate risk follicular lymphoma international prognostic index (FLIPI) and 9 of 25 patients (36%) with a high risk FLIPI were enrolled in this study. The delivered median number of chemotherapy was six (range, 2-9 cycles). The overall response rate with fludarabine-based treatment was 88%, including 52% complete remission and 36% partial remission. During the median follow-up of 19 months, the estimated 2-year event-free survival was 63±10% (95% CI, 43-83) and the 2-year overall survival was 78±9% (95% CI, 60-96). Fludarabine combination chemotherapy was frequently associated with grade 3 or 4 neutropenia in 84% patients. However, neutropenic infection was observed in only one (4%) patient. Four patients (16%) showed grade 3 or more non-hematologic toxicities, such as acute coronary syndrome, intracranial hemorrhage, anaphylaxis and gastric cancer. CONCLUSION Fludarabine-combination treatment was a highly active regimen with well toleration in untreated low-grade NHL.
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Affiliation(s)
- Jae-Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Park E. Low-grade lymphoma: Beyond fludarabine-single therapy. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:145-7. [PMID: 22065965 PMCID: PMC3208193 DOI: 10.5045/kjh.2011.46.3.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Eunkyung Park
- Division of Hematology and Oncology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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