Rituximab in Lymphoma and Chronic Lymphocytic Leukaemia: A Practice Guideline

Rituximab use in paediatric nephrology practice in Türkiye: TRTX

AIM

Rituximab (RTX) is a genetically engineered chimeric monoclonal antibody which binds directly to CD20 antigen and mediates inhibition of B cell development. Although RTX has been widely used in paediatric nephrology, there is no routine protocol for its use. In this study, paediatric nephrologists in Türkiye were asked to fill out a questionnaire to understand their practice in using RTX. This study aimed to determine common practices and clarify the uncertainties regarding the use of RTX in paediatric nephrology.

METHODS

This was a nationwide, multicenter, retrospective cohort study based on data evaluating the use of RTX in paediatric nephrology practice. An online questionnaire was sent to all paediatric nephrology centers in Türkiye. The questionnaire forms included information about how many patients in total applied RTX treatment, for which indications they use RTX, and whether they made any preparations before using RTX.

RESULTS

According to this survey on RTX use in Türkiye, paediatric nephrologists use it most commonly in SSNS and followed by SRNS, ABMR, SLE and AAV, respectively. Dosing was highly standard but there is significant heterogeneity in pre-exposure tests and patient monitoring in the clinical practice of RTX. Also, the rate of encountering RTX-related allergic and infectious side effects at least once during the professional experience of our physicians can be quite high.

CONCLUSION

There is an increasing need for the preparation of a guideline on the indications for RTX use for each diagnosis, posology, and the practices to be performed before and after infusion.

Indolent lymphoma care delivery and outcomes during the COVID-19 pandemic in Ontario, Canada

The treatment pattern and outcomes in patients with indolent B-cell lymphoma treated during the coronavirus disease 2019 (COVID-19) pandemic period compared to the prepandemic period are unclear. This was a retrospective population-based study using administrative databases in Ontario, Canada (follow-up to 31 March 2022). The primary outcome was treatment pattern; secondary outcomes were death, toxicities, healthcare utilization (emergency department [ED] visit, hospitalization) and SARS-CoV-2 outcomes. Adjusted hazard ratios (aHR) from Cox proportional hazards models were used to estimate associations. We identified 4143 patients (1079 pandemic, 3064 prepandemic), with a median age of 69 years. In both time periods, bendamustine (B) + rituximab (BR) was the most frequently prescribed regimen. During the pandemic, fewer patients received R maintenance or completed the full 2-year course (aHR 0.81, 95% CI 0.71-0.92, p = 0.001). Patients treated during the pandemic had less healthcare utilization (ED visit aHR 0.77, 95% CI 0.68, 0.88, p < 0.0001; hospitalization aHR 0.81, 95% CI 0.70-0.94, p = 0.0067) and complications (infection aHR 0.69, 95% CI 0.57-0.82, p < 0.0001; febrile neutropenia aHR 0.66, 95% CI 0.47-0.94, p = 0.020), with no difference in death. Independent of vaccination, active rituximab use was associated with a higher risk of COVID-19 complications. Despite similar front-line regimen use, healthcare utilization and admissions for infection were less in the pandemic cohort.

Biologics in steroid resistant nephrotic syndrome in childhood: review and new hypothesis-driven treatment

Nephrotic syndrome affects about 2-7 per 100,000 children yearly and accounts for less than 15% of end stage kidney disease. Steroids still represent the cornerstone of therapy achieving remission in 75-90% of the cases The remaining part result as steroid resistant nephrotic syndrome, characterized by the elevated risk of developing end stage kidney disease and frequently presenting disease recurrence in case of kidney transplant. The pathogenesis of nephrotic syndrome is still far to be elucidated, however, efficacy of immune treatments provided the basis to suggest the involvement of the immune system in the pathogenesis of the disease. Based on these substrates, more immune drugs, further than steroids, were administered in steroid resistant nephrotic syndrome, such as antiproliferative and alkylating agents or calcineurin inhibitors. However, such treatments failed in inducing a sustained remission. In last two decades, the developments of monoclonal antibodies, including the anti-CD20 rituximab and inhibitor of B7-1 abatacept, represented a valid opportunity of treatment. However, also the effectiveness of biologics resulted limited. We here propose a new hypothesis-driven treatment based on the combining administration of rituximab with the anti-CD38 monoclonal antibody daratumumab (NCT05704400), sustained by the hypothesis to target the entire B-cells subtypes pool, including the long-lived plasmacells.

Bendamustine and rituximab is well-tolerated and efficient in the treatment of indolent non-Hodgkin's lymphoma and mantle cell lymphoma in elderly: A single center observational study

Bendamustine and rituximab (BR) is a preferred first-line therapy for indolent non-Hodgkin's lymphoma (iNHL) and mantle cell lymphoma (MCL); however, few reports on BR performance in elderly patients are available to date. We compared safety and efficacy of BR in patients ≥70 years (elderly) vs <70 years (younger) treated at our institution. Among 201 patients, 113 were elderly (median age: 77 years), including 38 patients ≥80 years, and 88 were younger (median age: 62 years). Elderly patients had more bone marrow involvement by lymphoma, anemia, ECOG status 3 and high-risk disease follicular lymphoma (P < .05 for all). Fifty-four percent of elderly received full dose of bendamustine vs 79.5% of younger patients. More elderly patients (54%) vs younger (43.2%) experienced treatment delay. Less elderly proceeded to rituximab maintenance. Overall, the number of adverse events per patient and transformed B-Cell lymphoma/secondary malignancies were similar between groups. Elderly patients had less febrile neutropenia, rituximab-associated infusion reactions, but more herpes zoster reactivation. There were more deaths in the elderly (37.2%) vs younger (10.2%) groups (P < .001), mainly due to non-lymphoma-related causes. With median follow-up of 42 months [4.0-97.0] disease-free survival for the elderly was similar to younger patients. There was no difference between patients <80 and ≥80 years (P = .274). In conclusion, the real-world elderly patients have more advanced disease and higher ECOG status. BR is well-tolerated; elderly patients had lower incidence of febrile neutropenia. Dose reduction and treatment delays are common, but BR efficacy was not affected even in very old patients (≥80 years).

IBRUTINIB FOR CONTROL OF CHOROIDAL AND ORBITAL METASTASIS FROM CHRONIC LYMPHOCYTIC LEUKEMIA

PURPOSE

To describe a case of choroidal and orbital metastasis of chronic lymphocytic leukemia controlled with ibrutinib monotherapy, an oral tyrosine kinase inhibitor.

METHODS

Single case report.

RESULTS

A 69-year-old man with a past medical history of chronic lymphocytic leukemia diagnosed 1 year previously was referred with a foveal lesion in the right eye and was found to have hyperopic shift in the right eye. Optical coherence tomography demonstrated choroidal infiltration in the right eye, and computed tomography of the orbits demonstrated a left orbital mass. Biopsy of the left orbital mass confirmed chronic lymphocytic leukemia/small lymphocytic leukemia. Oral ibrutinib monotherapy of 140 mg three times daily was initiated for treatment of these choroidal and orbital metastases, and at 6 months, there was clinical resolution of disease. Cessation of ibrutinib monotherapy was followed 7 months later by recurrence of choroidal disease. Reinitiation of ibrutinib monotherapy 140 mg three times daily led again to clinical disease resolution, and durable remission has been attained on a well-tolerated low maintenance dose of ibrutinib 140 mg two times daily.

CONCLUSION

This is the first reported case of control of choroidal and orbital metastasis of chronic lymphocytic leukemia with ibrutinib monotherapy, confirmed with choroidal recurrence on drug cessation and clinical resolution of disease on re-treatment.

Update on the subcutaneous administration of rituximab in Canadian cancer centres

Results of studies comparing subcutaneous (sc) with intravenous (iv) rituximab indicate that the two formulations are comparable in efficacy, but most patients and health care professionals prefer the sc route, commonly because of shorter chair time and reduced risk of infusion-related reactions. Recent Canadian data, including those from the scuba study reported here, support the results of earlier international studies showing a reduction in preparation and administration time with the sc formulation, lower cost of administration, and reduced drug wastage because of the fixed sc dosing. Given the significant time and cost savings of the sc formulation, that formulation is generally preferred over the iv formulation for the treatment of follicular lymphoma, diffuse large B cell lymphoma, and chronic lymphocytic leukemia.

Cryoglobulinemic vasculitis and glomerulonephritis: concerns in clinical practice

OBJECTIVE

Cryoglobulinemia often causes systemic vasculitis, thereby damaging to skin and internal organs including kidneys, even life-threatening. This review aimed to introduce the advances in understanding, detection, and treatment of this disease in recent years, with a particular concern to clinical practice.

DATA SOURCES

All the data in this review were from the English or Chinese literature in the PubMed and China National Knowledge Infrastructure databases as of March 2019.

STUDY SELECTION

This review selected important original articles, meaningful reviews, and some reports on cryoglobulinemia published in recent years and in history, as well as the guidelines for treatment of underlying diseases which lead to cryoglobulinemia.

RESULTS

Diagnosis of cryoglobulinemia relies on serum cryoglobulin test, in which to ensure that the blood sample temperature is not less than 37°C in the entire pre-analysis phase is the key to avoid false negative results. Cryoglobulinemic vasculitis (Cryo Vas), including cryoglobulinemic glomerulonephritis (Cryo GN), usually occurs in types II and III mixed cryoglobulinemia, and can also be seen in type I cryoglobulinemia caused by monoclonal IgG3 or IgG1. Skin purpura, positive serum rheumatoid factor, and decreased serum levels of C4 and C3 are important clues for prompting types II and III Cryo Vas. Renal biopsy is an important means for diagnosis of Cryo GN, while membranous proliferative GN is the most common pathological type of Cryo GN. In recent years, great advances have been made in the treatment of Cryo Vas and its underlying diseases, and this review has briefly introduced these advances.

CONCLUSIONS

Laboratory examinations of serum cryoglobulins urgently need standardization. The recent advances in the diagnosis and treatment of Cryo Vas and GN need to be popularized among the clinicians in related disciplines.

Canadian evidence-based guideline for the first-line treatment of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In Canada, no unified national guideline exists for the front-line treatment of cll; provincial guidelines vary and are largely based on funding. A group of clinical experts from across Canada developed a national evidence-based treatment guideline to provide health care professionals with clear guidance on the first-line management of cll. Consensus recommendations based on available evidence are presented for the first-line treatment of cll.

The Elevation of Cardio-Ankle Vascular Index in a Patient With Malignant Lymphoma Treated With a Combination Therapy of Rituximab and Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone

An increased risk of arteriosclerosis has been noted in cancer survivors. Currently, there are only a few reports available that consider the risk of arteriosclerosis in patients treated with chemotherapy. Patients with an advanced stage B-cell malignant lymphoma are typically treated with a combination therapy of rituximab and cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP). Complications such as diabetes mellitus (DM), hyperlipidemia (HL), and osteoporosis due to prednisolone and cardiotoxicity due to anthracyclines are well known. However, there are no studies that have investigated the link between R-CHOP therapy and arteriosclerosis. We discussed a patient with follicular lymphoma who was evaluated using cardio-ankle vascular index (CAVI) as an arterial stiffness parameter during R-CHOP therapy in this report. She achived complete remission after the eighth course therapy without complications such as hypertension (HT), HL, DM, and infection. This patient showed elevated CAVI with new plaque formation in the carotid arteries after the end of chemotherapy. These data indicate that R-CHOP therapy may progress the arteriosclerosis.

The influence of rituximab-containing chemotherapy on HCV load in patients with HCV-associated non-Hodgkin's lymphomas

Efficacy and safety of rituximab treatment in patients with Hepatitis C virus (HCV) infection associated non-Hodgkin's lymphoma (NHL) are still disputable. The aim of this study was to evaluate the influence of rituximab-containing chemotherapy on HCV load. Fifty-four patients with both HCV infection and NHL were identified between 2000 and 2016 at our institution. We retrospectively analyzed patients' demographic characteristics, treatment, and kinetics of HCV load before and after treatment with rituximab-containing chemotherapy. In the total group of 54 patients, 29 (54%) received rituximab. Both HCV load pre rituximab and maximal HCV load post rituximab were available in 16 patients. Overall, we observed no significant difference between HCV load pre rituximab and the maximal HCV load post rituximab (P = 0.19). In a patient who was treated simultaneously with direct-acting antivirals (DAAs) and rituximab-containing chemotherapy, HCV load decreased below the sensitivity level (≤12 IU/ml) during treatment. When regarding the influence of rituximab-containing chemotherapy alone on HCV load, we observed a significant elevation of HCV load (P = 0.04). Rituximab-containing chemotherapy may lead to an increase of HCV load in patients with HCV-associated NHL. However, this finding is based on small patient cohort and should be confirmed in larger clinical trials.

New biologics in the treatment of rare glomerular diseases of childhood

Minimal change disease and focal segmental glomerulosclerosis are rare but important causes of end-stage kidney disease in children. Though their pathogenesis is still unclear, evidence of immune abnormalities provided the background for the use of immunosuppressive drugs, such as corticosteroids, calcineurin inhibitors, antiproliferative and alkylating agents. Unfortunately, these treatments fail to achieve a sustained remission in a significant portion of patients and are burdened by significant toxicities. Recent developments of new biologics, including anti-CD20 monoclonal antibodies rituximab and ofatumumab, offered the opportunity to selectively target immune cell subsets or activation pathways, leading to more effective and safer hypothesis-driven treatments.