Role of antibody-based therapy in indolent non-Hodgkin's lymphoma

New and developing first line pharmacotherapies for treating non-Hodgkin lymphoma

INTRODUCTION

Non-Hodgkin lymphomas (NHLs) encompass a wide range of diseases from precancerous states such as monoclonal B-cell lymphocytosis to the rapidly growing Burkitt lymphoma. In 2022, we witnessed two new classifications for these malignant lymphoid tumors: The World Health Organization (WHO) 5th edition Classification of Haematolymphoid Tumours and the International Consensus Classification of Mature Lymphoid Neoplasms (ICC).

AREAS COVERED

Given our improved understanding of the mechanisms underlying lymphomagenesis at the molecular level, several novel agents have been or are being actively developed, including targeted therapies and immunotherapies. Therefore, this review features new and developing first-line pharmacotherapies in NHL. It is organized by the mechanism of action of the drug with the relevant key trials highlighted.

EXPERT OPINION

We provide an overview of the development of curative combination chemotherapies for lymphomas, and then discuss the importance of working on a unified classification for these tumors. We discuss resistance to targeted therapies, particularly with the continuous use of Bruton tyrosine kinase inhibitors, how to sequence T-cell therapies (bispecific T-cell engagers and chimeric antigen receptor therapy), and the impact of financial toxicity. We also review possible strategies to increase cure rates at lower costs, with less toxicity, and while promoting global health.

Immuno-PET Imaging and Radioimmunotherapy of Lymphomas

Monoclonal antibodies (Ab) have revolutionized the management of lymphomas, the most common hematologic malignancy in adults. Indeed, incorporation of rituximab into the regimen for indolent non-Hodgkin's lymphomas (NHLs) has dramatically improved treatment response and disease outcome. Yet, newer Ab therapeutics against promising antigen targets need to be developed to treat refractory or relapsed patients. Treatment efficacy can be further enhanced by conjugating toxic molecules to the Abs. Radioimmunotherapy (RIT) harnesses Abs as vehicles for targeted delivery of therapeutic radionuclide payloads for direct killing of targeted tumor cells. Positron emission tomography (PET) with radiolabeled Abs (called immuno-PET) can facilitate the development of new Ab therapeutics and RIT by providing pharmacokinetic and pharmacodynamic information and by quantifying tumor antigen level relevant for treatment decision. Immuno-PET has recently gravitated toward labeling Abs with ⁸⁹Zr, a radiometal with a 3.3 day half-life that is trapped following Ab internalization and thus provides high-resolution PET images with excellent contrast. Immuno-PET methods against major lymphoma antigens including CD20 and other promising targets are currently under development. With continued improvements, immuno-PET has the potential to be used in lymphoma management as an imaging biomarker for patient selection and assessment of treatment response.