1
|
Wierda WG, Shah NN, Cheah CY, Lewis D, Hoffmann MS, Coombs CC, Lamanna N, Ma S, Jagadeesh D, Munir T, Wang Y, Eyre TA, Rhodes JM, McKinney M, Lech-Maranda E, Tam CS, Jurczak W, Izutsu K, Alencar AJ, Patel MR, Seymour JF, Woyach JA, Thompson PA, Abada PB, Ho C, McNeely SC, Marella N, Nguyen B, Wang C, Ruppert AS, Nair B, Liu H, Tsai DE, Roeker LE, Ghia P. Pirtobrutinib, a highly selective, non-covalent (reversible) BTK inhibitor in patients with B-cell malignancies: analysis of the Richter transformation subgroup from the multicentre, open-label, phase 1/2 BRUIN study. Lancet Haematol 2024:S2352-3026(24)00172-8. [PMID: 39033770 DOI: 10.1016/s2352-3026(24)00172-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/17/2024] [Accepted: 05/23/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Richter transformation usually presents as an aggressive diffuse large B-cell lymphoma, occurs in up to 10% of patients with chronic lymphocytic leukaemia, has no approved therapies, and is associated with a poor prognosis. Pirtobrutinib has shown promising efficacy and tolerability in patients with relapsed or refractory B-cell malignancies, including those who progress on covalent Bruton tyrosine kinase (BTK) inhibitors. This study aims to report the safety and activity of pirtobrutinib monotherapy in a subgroup of patients with Richter transformation from the multicentre, open-label, phase 1/2 BRUIN study. METHODS This analysis included adult patients (aged ≥18 years) with histologically confirmed Richter transformation, an Eastern Cooperative Oncology Group performance status score of 0-2, and no limit of previous therapies, with patients receiving first-line treatment added in a protocol amendment (version 9.0, Dec 15, 2021). Pirtobrutinib 200 mg was administered orally once a day in 28-day cycles. The primary endpoint of phase 1 of the BRUIN trial as a whole, which has been previously reported, was to establish the recommended phase 2 dose for pirtobrutinib monotherapy and the phase 2 primary endpoint was overall response rate. Safety and activity were measured in all patients who received at least one dose of pirtobrutinib monotherapy. This BRUIN phase 1/2 trial was registered with ClinicalTrials.gov and is closed to enrolment (NCT03740529). FINDINGS Between Dec 26, 2019, and July 22, 2022, 82 patients were enrolled, of whom five were enrolled during phase 1 and 77 during phase 2. All but one patient received a starting dose of 200 mg pirtobrutinib once a day as the recommended phase 2 dose. The remaining patient received 150 mg pirtobrutinib once a day, which was not escalated to 200 mg. The median age of patients was 67 years (IQR 59-72). 55 (67%) of 82 patients were male and 27 (33%) were female. Most patients were White (65 [79%] of 82). 74 (90%) of 82 patients received at least one previous Richter transformation-directed therapy. Most patients (61 [74%] of 82) had received previous covalent BTK inhibitor therapy for chronic lymphocytic leukaemia or Richter transformation. The overall response rate was 50·0% (95% CI 38·7-61·3). 11 (13%) of 82 patients had a complete response and 30 (37%) of 82 patients had a partial response. Eight patients with ongoing response electively discontinued pirtobrutinib to undergo stem-cell transplantation. The most common grade 3 or worse adverse event was neutropenia (n=19). There were no treatment-related deaths. INTERPRETATION Pirtobrutinib shows promising safety and activity among patients with Richter transformation, most of whom received previous Richter transformation-directed therapy, including covalent BTK inhibitors. These data suggest that further investigation is warranted of pirtobrutinib as a treatment option for patients with relapsed or refractory Richter transformation after treatment with a covalent BTK inhibitor. FUNDING Loxo Oncology.
Collapse
Affiliation(s)
- William G Wierda
- The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Nirav N Shah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chan Y Cheah
- Linear Clinical Research and Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - David Lewis
- Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth, UK
| | - Marc S Hoffmann
- The University of Kansas Cancer Center, Kansas City, KS, USA
| | - Catherine C Coombs
- University of California Irvine Health, Chao Family Comprehensive Cancer Center, Orange, CA, USA
| | - Nicole Lamanna
- Herbert Irving Comprehensive Cancer Center, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Shuo Ma
- Robert H Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Deepa Jagadeesh
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Talha Munir
- Department of Haematology, St James's University Hospital, Leeds, UK
| | - Yucai Wang
- Department of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Churchill Cancer Centre, Oxford, UK
| | - Joanna M Rhodes
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Ewa Lech-Maranda
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Krakow, Poland
| | - Koji Izutsu
- National Cancer Center Hospital, Tokyo, Japan
| | - Alvaro J Alencar
- Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Manish R Patel
- Florida Cancer Specialists and Sarah Cannon Research Institute, Sarasota, FL, USA
| | - John F Seymour
- Alfred Hospital and Monash University, Melbourne, Australia
| | - Jennifer A Woyach
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | | | - Caleb Ho
- Loxo Oncology, Indianapolis, IN, USA
| | | | | | | | | | | | | | - Hui Liu
- Loxo Oncology, Indianapolis, IN, USA
| | | | | | - Paolo Ghia
- Università Vita-Salute San Raffaele and IRCCS Ospedale San Raffaele, Milan, Italy
| |
Collapse
|
2
|
Tadmor T. Overcoming the unmet need of Richter transformation: the use of pirtobrutinib. Lancet Haematol 2024:S2352-3026(24)00204-7. [PMID: 39033771 DOI: 10.1016/s2352-3026(24)00204-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/17/2024] [Indexed: 07/23/2024]
Affiliation(s)
- Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel; The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| |
Collapse
|
3
|
Negara I, Tomuleasa C, Buruiana S, Efremov DG. Molecular Subtypes and the Role of TP53 in Diffuse Large B-Cell Lymphoma and Richter Syndrome. Cancers (Basel) 2024; 16:2170. [PMID: 38927876 PMCID: PMC11201917 DOI: 10.3390/cancers16122170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/30/2024] [Accepted: 06/01/2024] [Indexed: 06/28/2024] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid malignancy and a heterogeneous entity comprised of several biologically distinct subtypes. Recently, novel genetic classifications of DLBCL have been resolved based on common mutational patterns indicative of distinct pathways of transformation. However, the complicated and costly nature of the novel classifiers has precluded their inclusion into routine practice. In view of this, the status of the TP53 gene, which is mutated or deleted in 20-30% of the cases, has emerged as an important prognostic factor for DLBCL patients, setting itself apart from other predictors. TP53 genetic lesions are particularly enriched in a genetic subtype of DLBCL that shares genomic features with Richter Syndrome, highlighting the possibility of a subset of DLBCL arising from the transformation of an occult chronic lymphocytic leukemia-like malignancy, such as monoclonal B-cell lymphocytosis. Patients with TP53-mutated DLBCL, including those with Richter Syndrome, have a particularly poor prognosis and display inferior responses to standard chemoimmunotherapy regimens. The data presented in this manuscript argue for the need for improved and more practical risk-stratification models for patients with DLBCL and show the potential for the use of TP53 mutational status for prognostication and, in prospect, treatment stratification in DLBCL.
Collapse
Affiliation(s)
- Ivan Negara
- Molecular Hematology Unit, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
- Department of Internal Medicine, Hematology, “Nicolae Testemitanu” State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania;
| | - Sanda Buruiana
- Department of Internal Medicine, Hematology, “Nicolae Testemitanu” State University of Medicine and Pharmacy, 2004 Chisinau, Moldova;
| | - Dimitar G. Efremov
- Molecular Hematology Unit, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
- Macedonian Academy of Sciences and Arts, 1000 Skopje, North Macedonia
| |
Collapse
|
4
|
Hampel PJ, Swaminathan M, Rogers KA, Parry EM, Burger JA, Davids MS, Ding W, Ferrajoli A, Hyak JM, Jain N, Kenderian SS, Wang Y, Wierda WG, Woyach JA, Parikh SA, Thompson PA. A multicenter study of venetoclax-based treatment for patients with Richter transformation of chronic lymphocytic leukemia. Blood Adv 2024; 8:2342-2350. [PMID: 38537065 PMCID: PMC11127193 DOI: 10.1182/bloodadvances.2023012080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/28/2024] [Indexed: 05/18/2024] Open
Abstract
ABSTRACT Patients with chronic lymphocytic leukemia (CLL) who develop Richter transformation (RT) have a poor prognosis when treated with chemoimmunotherapy regimens used for de novo diffuse large B-cell lymphoma. Venetoclax, a BCL2 inhibitor, has single-agent efficacy in patients with RT and is potentially synergistic with chemoimmunotherapy. In this multicenter, retrospective study, we evaluated 62 patients with RT who received venetoclax-based treatment outside of a clinical trial, in combination with a Bruton tyrosine kinase inhibitor (BTKi; n=28), rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) (n=13), or intensive chemoimmunotherapy other than R-CHOP (n=21). The best overall and complete response rates were 36%/25%, 54%/46%, and 52%/38%, respectively. The median progression-free and overall survival estimates for the same treatment groups were 4.9/14.3 months, 14.9 months/not reached, and 3.3/9 months, respectively. CLL with del(17p) was associated with a lower complete response rate in the total cohort (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.04-0.6; p=0.01) and venetoclax-naïve subgroup (OR 0.13; 95%CI 0.02-0.66; p=0.01). TP53 mutated CLL was associated with a lower complete response rate (OR 0.15; 95%CI 0.03-0.74; p=0.02) and shorter progression-free survival (hazard ratio 3.1; 95%CI 1.21-7.95; p=0.02) only in venetoclax-naïve subgroup. No other clinical or baseline characteristics, including prior venetoclax treatment for CLL, showed statistically significant association with outcomes. Grade 3-4 neutropenia and thrombocytopenia events were most frequent with intensive chemoimmunotherapy + venetoclax; grade 3-4 infection rates were similar across treatment groups. In this difficult-to-treat RT patient population, venetoclax-based combination regimens achieved high response rates, with durable remission and survival observed in a subset of patients.
Collapse
Affiliation(s)
- Paul J. Hampel
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mahesh Swaminathan
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Kerry A. Rogers
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Erin M. Parry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jan A. Burger
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Matthew S. Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Wei Ding
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | | | - Nitin Jain
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Saad S. Kenderian
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Yucai Wang
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - William G. Wierda
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | | | - Sameer A. Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Philip A. Thompson
- Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| |
Collapse
|
5
|
Qin S, Jiang R, Dai L, Miao Y, Sha Y, Qiu T, Ding C, Wang Z, Shi C, Xia Y, Fan L, Xu W, Li J, Zhu H. Venetoclax plus dose-adjusted R-EPOCH (VR-DA-EPOCH) or G-EPOCH bridging to subsequent cellular therapy for the patients with transformed lymphoma a single center clinical experience. Ann Hematol 2024; 103:1635-1642. [PMID: 38246951 PMCID: PMC11009738 DOI: 10.1007/s00277-024-05618-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Indolent lymphoma, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and follicular lymphoma (FL), can undergo histological transformation into an aggressive subtype, typically diffuse large B-cell lymphoma (DLBCL). The prognosis of transformed lymphoma is poor. In this study, we reported the efficacy and toxicity of a combination of venetoclax, dose-adjusted rituximab or obinutuzumab, etoposide, prednisone, vincristine, doxorubicin, and cyclophosphamide (VR-DA-EPOCH or VG-DA-EPOCH) in 11 patients with biopsy-proven histology transformation into DLBCL, including 8 patients with RT and 3 with transformed FL (tFL). The study was conducted between October 2019 and March 2023 at our single center. The median age of participants at enrolment was 53 years. Six patients (85.7%, 6/7) achieved complete remission (CR) at the end of treatment. The best overall response rate (ORR) and CR rate were both 72.7%, respectively. Two patients received autologous hemopoietic stem cell transplant (ASCT) while two patients received ASCT concurrently with CAR-T therapy for consolidation. With a median follow-up of 13.5 (range, 2.4-29.8) months after enrollment, the median event-free survival, progression-free survival, and overall survival were 9.4, 11.5, and 17.5 months, respectively. Hematologic toxicities of grade ≥3 consisted of neutropenia (90.9%, 10/11), thrombocytopenia (63.6%, 7/11), and febrile neutropenia (54.5%, 6/11). In conclusion, VR-DA-EPOCH or VG-DA-EPOCH was a promising strategy to achieve an early remission, bridging to cellular therapy within this population.
Collapse
Affiliation(s)
- Shuchao Qin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Rui Jiang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Luomengjia Dai
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Yi Miao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Yeqin Sha
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Tonglu Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Chongyang Ding
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Zhen Wang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Chuanbing Shi
- Department of Pathology, Pukou People's Hospital, Nanjing, 211800, Jiangsu, China
| | - Yi Xia
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Lei Fan
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Wei Xu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Huayuan Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China.
| |
Collapse
|
6
|
Bajwa A, Habib A, Kittai AS. Treatment of Richter's Transformation with Novel Therapies. Curr Hematol Malig Rep 2024; 19:45-55. [PMID: 38194201 PMCID: PMC10894755 DOI: 10.1007/s11899-023-00721-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review presents recently published clinical trial data and ongoing investigations regarding the treatment of Richter's transformation (RT). RECENT FINDINGS Recently, numerous approaches have been investigated for the treatment of RT including: traditional chemoimmunotherapy regimens combined with targeted agents such as BTKi and BCL2i; immunotherapy combined with targeted agents; non-covalent BTKis; bispecific T cell engagers; and CART therapy. In addition, various novel targeted agents are currently being studied for the treatment of RT in phase 1 and 2 clinical trials. Standard of care treatment with chemoimmunotherapy for RT has limited efficacy in achieving durable remissions. Here, we review recent data on the use of combination treatments and targeted agents in RT. Although some progress has been made in the investigation to optimize treatment of RT, further study is needed to evaluate long term outcomes of recently published trials and test efficacy of upcoming novel agents.
Collapse
Affiliation(s)
- Amneet Bajwa
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Alma Habib
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA
| | - Adam S Kittai
- The Ohio State University, 2121 Kenney Road, Columbus, OH, 43210, USA.
| |
Collapse
|
7
|
Pham N, Coombs CC, O'Brien S. Are we closer to a standard of care for Richter's syndrome? Novel treatments on the horizon. Expert Rev Hematol 2024; 17:117-126. [PMID: 38693662 DOI: 10.1080/17474086.2024.2350528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/29/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The therapeutic landscape for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has significantly evolved over the past decade with dramatically improved outcomes with the introduction of targeted therapies. This unfortunately has not been the case for Richter transformation (RT), the histologic transformation to a more aggressive lymphoma, most typically diffuse large B-cell lymphoma (DLBCL). As such, RT continues to be one of the most challenging complications of CLL/SLL. Historically, RT has a poor response to treatment, with a minority reaching complete remission (CR) and overall survival (OS) being less than a year. AREAS COVERED The focus of this review is to discuss the effectiveness of commonly used regimens, and review existing data for emerging regimens being examined in ongoing clinical trials to improve prognosis and outcomes in patients with RT. Despite extensive efforts to optimize therapies for RT, there is still no generalized consensus on either first-line treatment regimens or regimens in the relapsed/refractory setting. RT continues to carry a high mortality rate without durable response to current therapeutic agents. EXPERT OPINION Ongoing and future research may identify novel treatment approaches that will eventually improve outcomes for patients with RT. The optimal care for RT patients is a clinical trial, when feasible.
Collapse
MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/mortality
- Standard of Care
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Clinical Trials as Topic
- Molecular Targeted Therapy
- Treatment Outcome
- Disease Management
Collapse
Affiliation(s)
- Nghia Pham
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Catherine C Coombs
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Susan O'Brien
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| |
Collapse
|
8
|
Saluja S, Bansal I, Bhardwaj R, Beg MS, Palanichamy JK. Inflammation as a driver of hematological malignancies. Front Oncol 2024; 14:1347402. [PMID: 38571491 PMCID: PMC10987768 DOI: 10.3389/fonc.2024.1347402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 03/05/2024] [Indexed: 04/05/2024] Open
Abstract
Hematopoiesis is a tightly regulated process that produces all adult blood cells and immune cells from multipotent hematopoietic stem cells (HSCs). HSCs usually remain quiescent, and in the presence of external stimuli like infection or inflammation, they undergo division and differentiation as a compensatory mechanism. Normal hematopoiesis is impacted by systemic inflammation, which causes HSCs to transition from quiescence to emergency myelopoiesis. At the molecular level, inflammatory cytokine signaling molecules such as tumor necrosis factor (TNF), interferons, interleukins, and toll-like receptors can all cause HSCs to multiply directly. These cytokines actively encourage HSC activation, proliferation, and differentiation during inflammation, which results in the generation and activation of immune cells required to combat acute injury. The bone marrow niche provides numerous soluble and stromal cell signals, which are essential for maintaining normal homeostasis and output of the bone marrow cells. Inflammatory signals also impact this bone marrow microenvironment called the HSC niche to regulate the inflammatory-induced hematopoiesis. Continuous pro-inflammatory cytokine and chemokine activation can have detrimental effects on the hematopoietic system, which can lead to cancer development, HSC depletion, and bone marrow failure. Reactive oxygen species (ROS), which damage DNA and ultimately lead to the transformation of HSCs into cancerous cells, are produced due to chronic inflammation. The biological elements of the HSC niche produce pro-inflammatory cytokines that cause clonal growth and the development of leukemic stem cells (LSCs) in hematological malignancies. The processes underlying how inflammation affects hematological malignancies are still not fully understood. In this review, we emphasize the effects of inflammation on normal hematopoiesis, the part it plays in the development and progression of hematological malignancies, and potential therapeutic applications for targeting these pathways for therapy in hematological malignancies.
Collapse
|
9
|
Barrett A, Appleby N, Dreau H, Fox CP, Munir T, Eyre TA. Richter's transformation: Transforming the clinical landscape. Blood Rev 2024; 64:101163. [PMID: 38097488 DOI: 10.1016/j.blre.2023.101163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
Richter transformation (RT) represents an aggressive histological transformation from chronic lymphocytic leukaemia, most often to a large B cell lymphoma. It is characterised by chemo-resistance and subsequent short survival. Drug development has struggled over recent years in light of the aggressive kinetics of the disease, lack of pivotal registrational trials and relative rarity of the phenomenon. In this review we will highlight the diagnostic and therapeutic challenges of managing patients with RT as well as taking a look to the future therapeutic landscape. Highly active therapies developed across B cell malignancies are starting to impact this field, with T-cell activation therapies (CAR-T, bispecific antibodies), antibody-drug conjugates, and novel small molecule inhibitor combinations (e.g. BTKi-BCL2i) being actively studied. We will highlight the data supporting these developments and look to the studies to come to provide hope for patients suffering from this devastating disease.
Collapse
MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/therapy
- Cell Transformation, Neoplastic
Collapse
Affiliation(s)
- A Barrett
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - N Appleby
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - H Dreau
- Oxford Molecular Diagnostic Centre, Oxford, United Kingdom
| | - C P Fox
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - T Munir
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - T A Eyre
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| |
Collapse
|
10
|
Al-Sawaf O, Ligtvoet R, Robrecht S, Stumpf J, Fink AM, Tausch E, Schneider C, Boettcher S, Mikusko M, Ritgen M, Schetelig J, von Tresckow J, Vehling-Kaiser U, Gaska T, Wendtner CM, Chapuy B, Fischer K, Kreuzer KA, Stilgenbauer S, Staber P, Niemann C, Hallek M, Eichhorst B. Tislelizumab plus zanubrutinib for Richter transformation: the phase 2 RT1 trial. Nat Med 2024; 30:240-248. [PMID: 38071379 PMCID: PMC10803258 DOI: 10.1038/s41591-023-02722-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/15/2023] [Indexed: 01/24/2024]
Abstract
In patients with chronic lymphocytic leukemia, Richter transformation (RT) reflects the development of an aggressive lymphoma that is associated with poor response to chemotherapy and short survival. We initiated an international, investigator-initiated, prospective, open-label phase 2 study in which patients with RT received a combination of the PD-1 inhibitor tislelizumab plus the BTK inhibitor zanubrutinib for 12 cycles. Patients responding to treatment underwent maintenance treatment with both agents. The primary end point was overall response rate after six cycles. Of 59 enrolled patients, 48 patients received at least two cycles of treatment and comprised the analysis population according to the study protocol. The median observation time was 13.9 months, the median age was 67 (range 45-82) years. Ten patients (20.8%) had received previous RT-directed therapy. In total, 28 out of 48 patients responded to induction therapy with an overall response rate of 58.3% (95% confidence interval (CI) 43.2-72.4), including 9 (18.8%) complete reponse and 19 (39.6%) partial response, meeting the study's primary end point by rejecting the predefined null hypothesis of 40% (P = 0.008). Secondary end points included duration of response, progression-free survival and overall survival. The median duration of response was not reached, the median progression-free survival was 10.0 months (95% CI 3.8-16.3). Median overall survival was not reached with a 12-month overall survival rate of 74.7% (95% CI 58.4-91.0). The most common adverse events were infections (18.0%), gastrointestinal disorders (13.0%) and hematological toxicities (11.4%). These data suggest that combined checkpoint and BTK inhibition by tislelizumab plus zanubrutinib is an effective and well-tolerated treatment strategy for patients with RT. ClinicalTrials.gov Identifier: NCT04271956 .
Collapse
Affiliation(s)
- Othman Al-Sawaf
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany.
- Francis Crick Institute London, London, UK.
- Cancer Institute, University College London, London, UK.
| | - Rudy Ligtvoet
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Janina Stumpf
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Eugen Tausch
- Department III of Internal Medicine, University Hospital Ulm, Ulm, Germany
| | - Christof Schneider
- Department III of Internal Medicine, University Hospital Ulm, Ulm, Germany
| | - Sebastian Boettcher
- Department III of Internal Medicine, University Hospital Rostock, Rostock, Germany
| | - Martin Mikusko
- Department of Haematology and Oncology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, Campus Kiel, University of Schleswig-Holstein, Kiel, Germany
| | - Johannes Schetelig
- Department I of Internal Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Tobias Gaska
- Department of Hematology and Oncology, Brüderkrankenhaus St. Josef, Paderborn, Germany
| | | | - Bjoern Chapuy
- Department of Hematology and Medical Oncology, Georg-August University Göttingen, Göttingen, Germany
- Department of Hematology, Oncology, and Cancer Immunology, Charité -University Medical Center Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | | | - Philipp Staber
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Carsten Niemann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Michael Hallek
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany.
| |
Collapse
|
11
|
Eyre TA. Richter transformation-is there light at the end of this tunnel? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:427-432. [PMID: 38066897 PMCID: PMC10727096 DOI: 10.1182/hematology.2023000442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Richter transformation (RT) represents an uncommon (2% to 10%) but feared complication of chronic lymphocytic leukemia (CLL). The disease is characterized by rapid disease kinetics, a high-risk genetic mutational profile, chemoimmunotherapy resistance, and consequent poor survival. The typical overall survival (OS) from the pre-Bruton tyrosine kinase (BTK)/B-cell lymphoma 2 (BCL2) inhibitor CLL era is 6-12 months, and recent series of RT complicating progression on a BTK or BCL2 inhibitor in heavily pretreated relapsed CLL patients suggests an OS of only 3-4 months. Despite these sobering survival statistics, novel agents have the potential to impact the natural RT disease course. This article reviews recent therapeutic developments, focusing on inhibitors of BTK, BCL2, the PD1-PDL1 axis, and T-cell-activating/engaging therapies. Herein, I discuss the importance of randomized clinical trials in a disease where small single-arm studies dominate; industry engagement, including the role of registrational studies; and the need to integrate prospectively planned correlative biological studies embedded within future clinical trials to help discover which patient benefits most from each class or combination of novel targets.
Collapse
Affiliation(s)
- Toby A. Eyre
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| |
Collapse
|
12
|
Sousa-Pimenta M, Martins Â, Mariz JM, Berraondo P. Response to therapy in Richter syndrome: a systematic review with meta-analysis of early clinical trials. Front Immunol 2023; 14:1295293. [PMID: 38077330 PMCID: PMC10702133 DOI: 10.3389/fimmu.2023.1295293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/09/2023] [Indexed: 12/18/2023] Open
Abstract
Introduction and aims Richter syndrome (RS) represents the clonal evolution of chronic lymphocytic leukemia with histological transformation into a high-grade B cell lymphoma (diffuse large B cell lymphoma - DLBCL) or Hodgkin lymphoma. Considering that RS is an uncommon condition with poor prognosis, few high-quality evidence is available. To overcome this unmet need, this meta-analysis aimed to pool efficacy of early clinical trials in Richter syndrome (DLBCL subtype). Methods MEDLINE, Scopus and Web of Science were searched up to May of 2023 to identify clinical trials decoying efficacy. The pooled complete response, objective response and intension-to-treat failure rates were calculated by pharmacological categories (classical chemotherapy, immunochemotherapy, immunotherapy, Bruton-tyrosine kinase inhibitors, targeted approaches, cell-based therapies and combinatorial regimens) using the Der-Simonian and Laird random-effects model. The Freeman-Tukey double arcsine method was used to estimate variance and confidence intervals. Heterogeneity was assessed using the I2 method. Results Overall, from 1242 studies identified, 30 were included, pooling data from 509 patients. The higher efficacy rates when, cell-based therapies were excluded, were achieved by immunochemotherapeutic regimens followed by combinatorial regimens, with complete response rates of 21.54% (IC95%14.93-28.87) and 23.77% (IC95% 8.70-42.19), respectively. Bispecific antibodies (alone or coupled with a chemotherapy debulking strategy) overtook Bruton tyrosine kinase inhibitors response rates. The latter, although achieving objective response rates above average, presented scarce complete response rates. Checkpoint inhibitors alone usually do not lead to complete responses, but their effectiveness may improve when combined with other agents, unveiling the importance of immune microenvironmental modulation. Conclusion This is the first meta-analysis of early clinical trials assessing the impact of different therapeutics in RS. By analyzing the pooled efficacy estimates, our work suggests the role of a tailor-made bridging therapy for young patients with RS eligible for allogeneic hematopoietic stem cell transplantation (alloSCT), formally the only curative strategy.
Collapse
Affiliation(s)
- Mário Sousa-Pimenta
- Department of Hematology and Bone Marrow Transplantation, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
- i3S - Instituto de Investigação e Inovação em Saúde, Universidade do Porto, Porto, Portugal
- Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Ângelo Martins
- Department of Hematology and Bone Marrow Transplantation, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - José Mário Mariz
- Department of Hematology and Bone Marrow Transplantation, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - Pedro Berraondo
- Department of Immunology and Immunotherapy, Cima Universidad de Navarra, Pamplona, Spain
- Navarra Institute for Health Research (IDISNA), Pamplona, Spain
- Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| |
Collapse
|
13
|
Arun Kumar S, Gao J, Patel SA. The shifting therapeutic paradigm for relapsed/refractory mantle cell lymphoma. Leuk Res 2023; 134:107385. [PMID: 37672954 PMCID: PMC10888497 DOI: 10.1016/j.leukres.2023.107385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/08/2023]
Abstract
Mantle cell lymphoma (MCL) is a heterogeneous subtype of non-Hodgkin lymphoma that has been historically associated with poor 5-year overall survival rates, especially for aggressive variants. Traditional cytotoxic chemotherapy had been a mainstay of therapy for relapsed/refractory (R/R) MCL for many years until the advent of molecularly targeted therapies and cell-based approaches. However, a significant concern is the lack of definitive consensus guidelines for management of R/R MCL. The managerial conundrum partly stems from the absence of head-to-head comparisons of novel therapies, with conclusions drawn from cross-trial comparisons. In this evidence-based review, we discuss the current therapeutic options for R/R MCL, including the most recent data from the BRUIN study that led to the approval of the first-in-class non-covalent reversible Bruton's tyrosine kinase (BTK) inhibitor pirtobrutinib in 2023, as well as the recent removal of ibrutinib from the market. We discuss outlooks for targeted therapy and tolerability considerations for novel agents, including unique considerations for the elderly population. We highlight emerging data that support the curative potential of chimeric antigen receptor-T (CAR-T) therapy from ZUMA-2, relative to other promising investigational agents in the pipeline, including glofitamab, epcoritamab, and zilovertamab vedotin. We summarize management recommendations based upon the most rigorous clinical evidence to date.
Collapse
Affiliation(s)
- Sumukh Arun Kumar
- Dept. of Internal Medicine, Saint Vincent Hospital, Worcester, MA, USA
| | - Jenny Gao
- RNA Therapeutics Institute, UMass Chan Medical School, Worcester, MA, USA
| | - Shyam A Patel
- Center for Clinical and Translational Science (CCTS), UMass Chan Medical School, Worcester, MA, USA; Dept. of Medicine - Division of Hematology/Oncology, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA, USA.
| |
Collapse
|
14
|
Abrisqueta P, Nadeu F, Bosch-Schips J, Iacoboni G, Serna A, Cabirta A, Yáñez L, Quintanilla-Martínez L, Bosch F. From genetics to therapy: Unraveling the complexities of Richter transformation in chronic lymphocytic leukemia. Cancer Treat Rev 2023; 120:102619. [PMID: 37660626 DOI: 10.1016/j.ctrv.2023.102619] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
Richter transformation (RT) refers to the progression of chronic lymphocytic leukemia, the most prevalent leukemia among adults, into a highly aggressive lymphoproliferative disorder, primarily a diffuse large B-cell lymphoma. This is a severe complication that continues to be a therapeutic challenge and remains an unmet medical need. Over the last five years, significant advances have occurred in uncovering the biological processes leading to the RT, refining criteria for properly diagnose RT from other entities, and exploring new therapeutic options beyond the ineffective chemotherapy. This review summarizes current knowledge in RT, including recent advances in the understanding of the pathogenesis of RT, in the classification of RT, and in the development of novel therapeutic strategies for this grave complication.
Collapse
Affiliation(s)
- Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Ferran Nadeu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Jan Bosch-Schips
- Department of Pathology, Hospital Universitari de Bellvitge-Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Angel Serna
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Alba Cabirta
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Lucrecia Yáñez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Leticia Quintanilla-Martínez
- Institute of Pathology and Neuropathology, Tübingen University Hospital and Comprehensive Cancer Center Tübingen-Stuttgart, 72076 Tübingen, Germany
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain.
| |
Collapse
|
15
|
Parry EM, Roulland S, Okosun J. DLBCL arising from indolent lymphomas: How are they different? Semin Hematol 2023; 60:277-284. [PMID: 38072721 DOI: 10.1053/j.seminhematol.2023.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 03/12/2024]
Abstract
Transformation to diffuse large B-cell lymphoma (DLBCL) is a recognized, but unpredictable, clinical inflection point in the natural history of indolent lymphomas. Large retrospective studies highlight a wide variability in the incidence of transformation across the indolent lymphomas and the adverse outcomes associated with transformed lymphomas. Opportunities to dissect the biology of transformed indolent lymphomas have arisen with evolving technologies and unique tissue collections enabling a growing appreciation, particularly, of their genetic basis, how they relate to the preceding indolent lymphomas and the comparative biology with de novo DLBCL. This review summarizes our current understanding of both the clinical and biological aspects of transformed lymphomas and the outstanding questions that remain.
Collapse
Affiliation(s)
- Erin M Parry
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Harvard Medical School, Boston, MA; Broad Institute of MIT and Harvard, Cambridge, MA
| | - Sandrine Roulland
- Aix-Marseille University, CNRS, INSERM, Centre d'Immunologie de Marseille-Luminy, Marseille, France
| | - Jessica Okosun
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK; Department of Haemato-Oncology, St Bartholomew's Hospital, London, UK.
| |
Collapse
|
16
|
Romano I, Condoluci A, Rossi D. SOHO State of the Art Updates and Next Questions | Treatment of Richter's Transformation. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:786-799. [PMID: 37586917 DOI: 10.1016/j.clml.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023]
Abstract
Richter's transformation (RT) is a rare condition, represented by the development of an aggressive lymphoma arising from underlying chronic lymphocytic leukemia/small lymphocytic lymphoma. The management of RT remains challenging, necessitating combined therapeutic strategies to achieve favorable outcomes. Traditional treatment options for RT have involved intensive chemotherapy regimens, often with limited success due to the high-risk nature of the disease. However, recent advances in the understanding of RT pathogenesis have led to the emergence of novel targeted therapies that show promising results. Noncovalent Bruton tyrosine kinase inhibitors, T-cell-engaging bispecific antibodies, chimeric antigen receptor T-cells, and conjugated monoclonal antibodies may hold promise for improved outcomes in RT, especially when combined in a multitargeted fashion. Further prospective randomized trials and collaborative efforts are warranted to optimize treatment algorithm and ultimately improve patient outcomes in this dismal condition. This review provides a comprehensive overview of the current treatment options for RT.
Collapse
Affiliation(s)
- Ilaria Romano
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Adalgisa Condoluci
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Davide Rossi
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland; Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland..
| |
Collapse
|
17
|
Audil HY, Kosydar SR, Larson DP, Parikh SA. Richter Transformation of Chronic Lymphocytic Leukemia-Are We Making Progress? Curr Hematol Malig Rep 2023; 18:144-157. [PMID: 37294394 DOI: 10.1007/s11899-023-00701-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The treatment paradigm of chronic lymphocytic leukemia (CLL) has dramatically changed with the advent of novel targeted agents over the past decade. Richter transformation (RT), or the development of an aggressive lymphoma from a background of CLL, is a well-recognized complication of CLL and carries significantly poor clinical outcomes. Here, we provide an update on current diagnostics, prognostication, and contemporary treatment of RT. RECENT FINDINGS Several genetic, biologic, and laboratory markers have been proposed as candidate risk factors for the development of RT. Although a diagnosis of RT is typically suspected based on clinical and laboratory findings, tissue biopsy is essential for histopathologic confirmation of diagnosis. The standard of care for RT treatment at this time remains chemoimmunotherapy with the goal of proceeding to allogeneic stem cell transplantation in eligible patients. Several newer treatment modalities are being studied for use in the management of RT, including small molecules, immunotherapy, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T) therapy. The management of patients with RT remains a challenge. Ongoing trials show enormous promise for newer classes of therapy in RT, with the hope being that these agents can synergize, and perhaps supersede, the current standard of care in the near future.
Collapse
MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Immunotherapy
- Biopsy
- Cell Transformation, Neoplastic/genetics
Collapse
Affiliation(s)
- Hadiyah Y Audil
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel R Kosydar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel P Larson
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Sameer A Parikh
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
18
|
Levy Yurkovski I, Tadmor T. Accelerated Chronic Lymphocytic Leukemia and Richter Transformation in the Era of Novel Agents. Acta Haematol 2023; 147:73-83. [PMID: 37666234 DOI: 10.1159/000533664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Tremendous developments in the field of chronic lymphocytic leukemia (CLL) in recent years have led to a revolutionary change in the treatment approach, which today is based on targeted treatments with a good response and optimal prognosis. Nevertheless, CLL can present or progress to "accelerated CLL" (A-CLL) or to "Richter transformation" (RT) and these two entities have a more aggressive course and are still characterized by challenges in the fields of diagnosis and therapy. In the current review, we summarized the latest knowledge in terms of diagnostic approaches to A-CLL, available treatments and clinical trials, for both A-CLL and RT which still pose an unmet need and require additional basic and clinical investigations. SUMMARY A-CLL is a rare and underdiagnosed entity that probably stands in the "gray zone" between CLL and RT, generally holding an intermediate prognosis. Its diagnosis is mainly based on histological findings including expanded proliferation centers, increased mitotic activity, and/or high Ki-67 index. Due to its rarity, its treatment approach has still not been defined, but it seems that novel agents, especially Bruton tyrosine kinase inhibitors (BTKi), are effective. As for RT, the standard therapy still consists of chemo-immunotherapy followed by stem-cell transplantation for fit responders with a dismal prognosis. New approaches are recently adopted including B-cell inhibition via novel agents (BTKi, venetoclax), T-cell engagers (checkpoint inhibitors, bispecific antibodies [BiTe] or the chimeric antigen receptor [CAR] technology), antibody-drug conjugates, or drug combinations. Although both CAR-T and BiTe seem promising, especially when combined with BTKi, evidence is still insufficient, and patients should generally be recruited in clinical trials. KEY MESSAGES The field of CLL has been a subject of major advances in recent years, but A-CLL and RT remain topics of "unmet need" and require further studies to identify the best diagnostic approach and a more effective treatment.
Collapse
Affiliation(s)
- Ilana Levy Yurkovski
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
19
|
Jain N, Senapati J, Thakral B, Ferrajoli A, Thompson P, Burger J, Basu S, Kadia T, Daver N, Borthakur G, Konopleva M, Pemmaraju N, Parry E, Wu CJ, Khoury J, Bueso-Ramos C, Garg N, Wang X, Lopez W, Ayala A, O’Brien S, Kantarjian H, Keating M, Allison J, Sharma P, Wierda W. A phase 2 study of nivolumab combined with ibrutinib in patients with diffuse large B-cell Richter transformation of CLL. Blood Adv 2023; 7:1958-1966. [PMID: 36287248 PMCID: PMC10189379 DOI: 10.1182/bloodadvances.2022008790] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/20/2022] Open
Abstract
Richter transformation (RT) is a rare complication of chronic lymphocytic leukemia (CLL) that has dismal outcomes. Upregulation of PD-1/PD-L1 drives immunological evasion in patients with RT. We hypothesized that combining nivolumab, a PD-1 blocking antibody, with the BTK inhibitor (BTKi) ibrutinib could potentiate tumor-cell killing. We conducted an investigator-initiated phase 2 clinical trial to assess the efficacy of combined nivolumab and ibrutinib in patients with diffuse large B-cell lymphoma (DLBCL) RT and CLL. Patients included were ≥18 years of age with adequate hepatic and renal function. Patients received nivolumab every 2 weeks of a 4-week cycle for a maximum of 24 cycles. A standard dose ibrutinib was initiated from cycle 2 onward and continued daily until progression. For patients who were already on ibrutinib at the time of study entry, the same was continued while nivolumab was initiated. A total of 24 patients with RT with a median age of 64.5 years (range, 47-88) were enrolled. Ten patients (42%) had received prior treatment for RT and 13 patients (54%) had received a prior BTKi. A total of 10 patients (42%) responded with a median duration of response of 15 months. The median overall survival was 13 months. Four of 24 (17%) patients had checkpoint inhibition-related immunological toxicities. In the CLL cohort, 10 patients were enrolled, of whom 3 patients converted from partial to complete remission; 1 patient had a grade 2 immunological toxicity. Combined nivolumab and ibrutinib is an active regimen for patients with DLBCL RT with an overall response rate of 42%. Given the limited treatment options for patients with RT, checkpoint inhibition provides a potential therapeutic option. This trial is registered at www.clinicaltrials.gov as #NCT02420912.
Collapse
Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beenu Thakral
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sreyashi Basu
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erin Parry
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Catherine J. Wu
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Joseph Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Garg
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wanda Lopez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ana Ayala
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O’Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James Allison
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Padmanee Sharma
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
20
|
Tam C, Munoz J, Cull G, Opat S, Allewelt H, Zhang X, Stern JC, Hilger J, By K, Cohen A, Tedeschi A. Zanubrutinib, Alone and in Combination With Tislelizumab, for the Treatment of Richter Transformation of Chronic Lymphocytic Leukemia. Hemasphere 2023; 7:e870. [PMID: 36999005 PMCID: PMC10043571 DOI: 10.1097/hs9.0000000000000870] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/13/2023] [Indexed: 04/01/2023] Open
Affiliation(s)
- Constantine Tam
- Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Javier Munoz
- Banner MD Anderson Cancer Center, Gilbert, AZ, USA
| | - Gavin Cull
- Sir Charles Gairdner Hospital, Perth, WA, Australia
- University of Western Australia, Perth, WA, Australia
| | - Stephen Opat
- Monash Health, Clayton, VIC, Australia
- Monash University, Clayton, VIC, Australia
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Pepin X, McAlpine V, Moir A, Mann J. Acalabrutinib Maleate Tablets: The Physiologically Based Biopharmaceutics Model behind the Drug Product Dissolution Specification. Mol Pharm 2023; 20:2181-2193. [PMID: 36859819 DOI: 10.1021/acs.molpharmaceut.3c00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Acalabrutinib maleate tablets correspond to an improved formulation compared to acalabrutinib capsules as they can be dosed with and without acid reducing agents and therefore benefit more cancer patients. The dissolution specification for the drug product was determined using all the information available on the drug safety, efficacy, and in vitro performance. In addition, a physiologically based biopharmaceutics model was developed for acalabrutinib maleate tablets on the back of a previously published model for acalabrutinib capsules to establish that the proposed drug product dissolution specification would ensure safe and effective products for all patients including those under acid reducing agent treatment. The model was built, validated, and used to predict the exposure of virtual batches where the dissolution was slower than that of the clinical target. A combination of exposure prediction and the use of a PK-PD model allowed it to be demonstrated that the proposed drug product dissolution specification was acceptable. This combination of models enabled a larger safe space than would have been granted by consideration of bioequivalence only.
Collapse
Affiliation(s)
- Xavier Pepin
- New Modalities and Parenteral Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, Charter Way, SK10 2NA Macclesfield, United Kingdom
| | - Vivien McAlpine
- Oral Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, SK10 2NA Macclesfield, United Kingdom
| | - Andrea Moir
- Oral Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, SK10 2NA Macclesfield, United Kingdom
| | - James Mann
- Oral Product Development, Pharmaceutical Technology & Development, Operations, AstraZeneca, SK10 2NA Macclesfield, United Kingdom
| |
Collapse
|
22
|
Smyth E, Eyre TA, Cheah CY. Emerging Therapies for the Management of Richter Transformation. J Clin Oncol 2023; 41:395-409. [PMID: 36130148 DOI: 10.1200/jco.22.01028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Richter transformation (RT) refers to the development of an aggressive lymphoma in patients with underlying chronic lymphocytic leukemia/small lymphocytic lymphoma. Aside from a small subgroup of patients with clonally unrelated and previously untreated chronic lymphocytic leukemia, the disease responds poorly to standard therapies and prognosis is dismal. Recent developments in the understanding of the biology of RT and the advent of several targeted agents may result in improved outcomes for these patients. The purpose of this review is to analyze recent data on the pathogenesis and treatment of RT. We reviewed studies addressing the pathophysiology of RT and analyzed the data for frontline chemoimmunotherapy and emerging targeted therapies likely to play a significant role in the future management of RT. Several biologic and clinical factors may help identify those who are unlikely to respond to conventional chemoimmunotherapy; where possible, these patients should be managed with a novel approach. Emerging therapies for the management of RT include chimeric antigen receptor T-cell therapy, noncovalent Bruton tyrosine kinase inhibitors, and T-cell-engaging bispecific antibodies. The use of less toxic and more effective targeted therapies may result in improved outcomes. Larger, prospective clinical trials are required to confirm efficacy and safety of novel agents for the management of RT, particularly when used in combination with other targeted therapies and in addition to chemoimmunotherapy regimens.
Collapse
Affiliation(s)
- Elizabeth Smyth
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Toby A Eyre
- Haematology and Cancer Centre, Oxford University Hospitals NHS Foundation Trust Oxford, Oxford, United Kingdom
| | - Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
23
|
Ryan CE, Davids MS. Practical Management of Richter Transformation in 2023 and Beyond. Am Soc Clin Oncol Educ Book 2023; 43:e390804. [PMID: 37141545 DOI: 10.1200/edbk_390804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
While the past decade has witnessed unprecedented progress for patients with chronic lymphocytic leukemia (CLL), outcomes for patients with Richter transformation (RT) remain dismal. Multiagent chemoimmunotherapy regimens, such as rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone, are commonly used, although outcomes are far poorer than observed with the same regimens used in de novo diffuse large B-cell lymphoma. The revolutionary targeted therapies approved for CLL, such as inhibitors of Bruton tyrosine kinase and B-cell leukemia/lymphoma-2, have limited activity in RT as monotherapy, and initial promising activity of checkpoint blockade antibodies was also eventually found to be ineffective as monotherapy for most patients. Over the past few years, as outcomes for patients with CLL improved, there has been a growing focus of the research community on improving our biological understanding of the underlying pathophysiology of RT and on translating these new insights into rational combination strategies that are poised to improve therapeutic outcomes. Here, we present a brief overview of the biology and diagnosis of RT, as well as prognostic considerations, before providing a summary of the data supporting various therapies that have been recently studied in RT. We then turn our attention to the horizon and describe several of the promising novel approaches under investigation to treat this challenging disease.
Collapse
Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| |
Collapse
|
24
|
Treatment of Richter's syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:329-336. [PMID: 36485138 PMCID: PMC9820569 DOI: 10.1182/hematology.2022000345] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Richter's syndrome (RS) is an aggressive histologic transformation of chronic lymphocytic leukemia (CLL), most commonly to diffuse large B-cell lymphoma (DLBCL). Outcomes are generally poor, with complete remission (CR) rates of only about 20% and less than 20% long-term survival with chemoimmunotherapy (CIT). RS is biologically heterogeneous, and in 80% of patients with CLL who develop DLBCL, the disease is clonally related to the CLL. Clonally unrelated cases are genetically and immunologically distinct from clonally related DLBCL-RS, have more favorable responses to CIT, and are best treated as de novo DLBCL. Relatively favorable outcomes with CIT are also seen in patients who have never previously received treatment for CLL and who lack TP53 mutation or deletion. For the remaining patients, treatment on a clinical trial is optimal. Fortunately, numerous agents are now in clinical development that show encouraging results. Here we review clinical data for some of the most promising approaches. DLBCL-RS tumor cells frequently express programmed cell death 1 protein (PD-1), and several studies have demonstrated activity for PD-1 inhibitors, especially in combination with ibrutinib. The BCL2 inhibitor venetoclax in combination with R-EPOCH CIT achieved CR in 50% of patients, and a study of venetoclax-R-CHOP is ongoing. The noncovalent Bruton's tyrosine kinase inhibitor pirtobrutinib has achieved responses in approximately two-thirds of heavily pretreated patients and, given its favorable toxicity profile, appears ideally suited to combining with other active agents. Finally, we review available data for bispecific antibodies, antibody-drug conjugates, and chimeric antigen receptor T-cell therapy, which, after revolutionizing the treatment of DLBCL, are now being evaluated in RS.
Collapse
|
25
|
Old and New Facts and Speculations on the Role of the B Cell Receptor in the Origin of Chronic Lymphocytic Leukemia. Int J Mol Sci 2022; 23:ijms232214249. [PMID: 36430731 PMCID: PMC9693457 DOI: 10.3390/ijms232214249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
The engagement of the B cell receptor (BcR) on the surface of leukemic cells represents a key event in chronic lymphocytic leukemia (CLL) since it can lead to the maintenance and expansion of the neoplastic clone. This notion was initially suggested by observations of the CLL BcR repertoire and of correlations existing between certain BcR features and the clinical outcomes of single patients. Based on these observations, tyrosine kinase inhibitors (TKIs), which block BcR signaling, have been introduced in therapy with the aim of inhibiting CLL cell clonal expansion and of controlling the disease. Indeed, the impressive results obtained with these compounds provided further proof of the role of BcR in CLL. In this article, the key steps that led to the determination of the role of BcR are reviewed, including the features of the CLL cell repertoire and the fine mechanisms causing BcR engagement and cell signaling. Furthermore, we discuss the biological effects of the engagement, which can lead to cell survival/proliferation or apoptosis depending on certain intrinsic cell characteristics and on signals that the micro-environment can deliver to the leukemic cells. In addition, consideration is given to alternative mechanisms promoting cell proliferation in the absence of BcR signaling, which can explain in part the incomplete effectiveness of TKI therapies. The role of the BcR in determining clonal evolution and disease progression is also described. Finally, we discuss possible models to explain the selection of a special BcR set during leukemogenesis. The BcR may deliver activation signals to the cells, which lead to their uncontrolled growth, with the possible collaboration of other still-undefined events which are capable of deregulating the normal physiological response of B cells to BcR-delivered stimuli.
Collapse
|
26
|
Alu A, Lei H, Han X, Wei Y, Wei X. BTK inhibitors in the treatment of hematological malignancies and inflammatory diseases: mechanisms and clinical studies. J Hematol Oncol 2022; 15:138. [PMID: 36183125 PMCID: PMC9526392 DOI: 10.1186/s13045-022-01353-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022] Open
Abstract
Bruton's tyrosine kinase (BTK) is an essential component of multiple signaling pathways that regulate B cell and myeloid cell proliferation, survival, and functions, making it a promising therapeutic target for various B cell malignancies and inflammatory diseases. Five small molecule inhibitors have shown remarkable efficacy and have been approved to treat different types of hematological cancers, including ibrutinib, acalabrutinib, zanubrutinib, tirabrutinib, and orelabrutinib. The first-in-class agent, ibrutinib, has created a new era of chemotherapy-free treatment of B cell malignancies. Ibrutinib is so popular and became the fourth top-selling cancer drug worldwide in 2021. To reduce the off-target effects and overcome the acquired resistance of ibrutinib, significant efforts have been made in developing highly selective second- and third-generation BTK inhibitors and various combination approaches. Over the past few years, BTK inhibitors have also been repurposed for the treatment of inflammatory diseases. Promising data have been obtained from preclinical and early-phase clinical studies. In this review, we summarized current progress in applying BTK inhibitors in the treatment of hematological malignancies and inflammatory disorders, highlighting available results from clinical studies.
Collapse
Affiliation(s)
- Aqu Alu
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Hong Lei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, 610041, China.
| |
Collapse
|
27
|
Richter Syndrome: From Molecular Pathogenesis to Druggable Targets. Cancers (Basel) 2022; 14:cancers14194644. [PMID: 36230566 PMCID: PMC9563287 DOI: 10.3390/cancers14194644] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Richter syndrome (RS) represents the occurrence of an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL), in patients with chronic lymphocytic leukemia (CLL). Most cases of RS originate from the direct transformation of CLL, whereas 20% are de novo DLBCL arising as secondary malignancies. Multiple molecular mechanisms contribute to RS pathogenesis. B-cell receptor (BCR) overreactivity to multiple autoantigens is due to frequent stereotyped BCR configuration. Genetic lesions of TP53, CDKN2A, NOTCH1 and c-MYC deregulate DNA damage response, tumor suppression, apoptosis, cell cycle and proliferation. Hyperactivation of Akt and NOTCH1 signaling also plays a role. Altered expression of PD-1/PD-L1 and of other immune checkpoints leads to RS resistance to cytotoxicity exerted by T-cells. The molecular features of RS provide vulnerabilities for therapy. Targeting BCR signaling with noncovalent BTK inhibitors shows encouraging results, as does the combination of BCL2 inhibitors with chemoimmunotherapy. The association of immune checkpoint inhibitors with BCL2 inhibitors and anti-CD20 monoclonal antibodies is explored in early phase clinical trials with promising results. The development of patient-derived xenograft mice models reveals new molecular targets for RS, exemplified by ROR1. Although RS still represents an unmet medical need, understanding its biology is opening new avenues for precision medicine therapy.
Collapse
|
28
|
Dong R, Yan Y, Zeng X, Lin N, Tan B. Ibrutinib-Associated Cardiotoxicity: From the Pharmaceutical to the Clinical. Drug Des Devel Ther 2022; 16:3225-3239. [PMID: 36164415 PMCID: PMC9508996 DOI: 10.2147/dddt.s377697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/06/2022] [Indexed: 12/06/2022] Open
Abstract
Ibrutinib is the first-in-class Bruton tyrosine kinase (BTK) inhibitor that has revolutionized the treatment of B cell malignancies. Unfortunately, increased incidences of cardiotoxicity have limited its use. Despite over a decade of research, the biological mechanisms underlying ibrutinib cardiotoxicity remain unclear. In this review, we discuss the pharmacological properties of ibrutinib, the incidence and mechanisms of ibrutinib-induced cardiotoxicity, and practical management to prevent and treat this condition. We also synopsize and discuss the cardiovascular adverse effects related to other more selective BTK inhibitors, which may guide the selection of appropriate BTK inhibitors.
Collapse
Affiliation(s)
- Rong Dong
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
| | - Youyou Yan
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
| | - Nengming Lin
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, 31006, People’s Republic of China
- Nengming Lin, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 903, No. 7 Building, Hangzhou, People’s Republic of China, Tel/Fax +86-571-56005600, Email
| | - Biqin Tan
- Department of Clinical Pharmacy, Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, People’s Republic of China
- Correspondence: Biqin Tan, Department of Clinical Pharmacy, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Room 207, No. 5 Building, Hangzhou, People’s Republic of China, Tel +86-571-56007824, Fax +86-571-56005600, Email
| |
Collapse
|
29
|
Burke JM. SOHO State of the Art Updates and Next Questions | Management of Most Difficult Cases of Chronic Lymphocytic Leukemia: Relapse After Both BTK and BCL2 Inhibition and Richter Transformation. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:427-435. [PMID: 35577753 DOI: 10.1016/j.clml.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/03/2022] [Accepted: 04/14/2022] [Indexed: 06/15/2023]
Abstract
The introduction of targeted therapies in chronic lymphocytic leukemia (CLL) has ushered in a new era in which patients achieve better control of their disease, survive longer, and experience fewer toxicities than before. Despite this progress, a subgroup of patients with CLL will develop resistance to both Bruton tyrosine kinase (BTK) and B-cell lymphoma 2 inhibitors. In addition, a subgroup of CLL cases will transform into aggressive lymphoma - called Richter transformation - either before or during targeted therapy. These two subgroups of patients have a poor prognosis, and available therapies lead to long-term remission in only a minority of patients. In this paper, two cases are presented that are reflective of these difficult scenarios. In the first case, a patient with CLL, complex karyotype, del 17p, and a mutation in TP53 experiences progression after ibrutinib, venetoclax, bendamustine, rituximab, and idelalisib. In the second case, a patient with CLL and del 17p develops a Richter transformation to diffuse large B-cell lymphoma after treatment with obinutuzumab, chlorambucil, ibrutinib, venetoclax, and idelalisib. The aggressive lymphoma is refractory to chemoimmunotherapy, and she expires. The literature pertaining to these two scenarios is reviewed, including the role of available targeted therapies, chemoimmunotherapy, and hematopoietic cell transplantation. Emerging novel therapies, including reversible BTK inhibitors and CAR T cell therapy, are discussed.
Collapse
|
30
|
Barbanti MC, Appleby N, Kesavan M, Eyre TA. Cellular Therapy in High-Risk Relapsed/Refractory Chronic Lymphocytic Leukemia and Richter Syndrome. Front Oncol 2022; 12:888109. [PMID: 35574335 PMCID: PMC9095984 DOI: 10.3389/fonc.2022.888109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the development of highly effective, targeted inhibitors of B-cell proliferation and anti-apoptotic pathways in chronic lymphocytic leukemia (CLL), these treatments are not curative, and many patients will develop either intolerance or resistance to these treatments. Transformation of CLL to high-grade lymphoma—the so-called Richter syndrome (RS)—remains a highly chemoimmunotherapy-resistant disease, with the transformation occurring following targeted inhibitors for CLL treatment being particularly adverse. In light of this, cellular therapy in the form of allogenic stem cell transplantation and chimeric antigen receptor T-cell therapy continues to be explored in these entities. We reviewed the current literature assessing these treatment modalities in both high-risk CLL and RS. We also discussed their current limitations and place in treatment algorithms.
Collapse
Affiliation(s)
- Maria Chiara Barbanti
- Department of Clinical Haematology, Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,Clinical Trials Unit, Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Trust, University of Oxford, Oxford, United Kingdom
| | - Niamh Appleby
- Department of Clinical Haematology, Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,Clinical Trials Unit, Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Trust, University of Oxford, Oxford, United Kingdom
| | - Murali Kesavan
- Department of Clinical Haematology, Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,Clinical Trials Unit, Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Trust, University of Oxford, Oxford, United Kingdom
| | - Toby Andrew Eyre
- Department of Clinical Haematology, Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,Clinical Trials Unit, Department of Oncology, Churchill Hospital, Oxford University Hospitals NHS Trust, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
31
|
Condoluci A, Rossi D. Biology and Treatment of Richter Transformation. Front Oncol 2022; 12:829983. [PMID: 35392219 PMCID: PMC8980468 DOI: 10.3389/fonc.2022.829983] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/25/2022] [Indexed: 12/28/2022] Open
Abstract
Richter transformation (RT), defined as the development of an aggressive lymphoma on a background of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), represents a clinical unmet need because of its dismal prognosis. An increasing body of knowledge in the field of RT is arising from the recent development of preclinical models depicting the biology underlying this aggressive disease. Consistently, new therapeutic strategies based on a genetic rationale are exploring actionable pathogenic pathways to improve the outcome of patients in this setting. In this review, we summarize the current understandings on RT biology and the available treatment options.
Collapse
Affiliation(s)
- Adalgisa Condoluci
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
| | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Richter's transformation (RT) occurs when chronic (CLL) transforms into an aggressive lymphoma. Despite improvements in the treatment of CLL, prognosis for RT remains poor. Here, we review current literature of RT, with a focus on novel treatment options. RECENT FINDINGS Efforts are underway to improve outcomes for patients with RT. While small molecule inhibitors have limited efficacy as monotherapy, recent developments combining them with chemo-immunotherapy show promise. Studies exploring the use of cellular therapies including chimeric antigen receptor T-cells and bispecific antibodies are ongoing. The current treatment paradigm for RT is to enroll these patients on a clinical trial when available, together with consultation for a consolidative allogeneic stem cell transplant. Trials investigating novel combinations and cellular therapy are ongoing. Determining predictive variables of transformation is imperative to design studies that allow for early identification and intervention for patients with RT.
Collapse
Affiliation(s)
- Audrey M Sigmund
- Division of Hematology, Department of Internal Medicine, The Ohio State University, 11th Floor Lincoln Tower and 1140D Lincoln Tower, 1800 Cannon Drive, Columbus, OH, 43210, USA
| | - Adam S Kittai
- Division of Hematology, Department of Internal Medicine, The Ohio State University, 11th Floor Lincoln Tower and 1140D Lincoln Tower, 1800 Cannon Drive, Columbus, OH, 43210, USA.
| |
Collapse
|
33
|
Iannello A, Deaglio S, Vaisitti T. Novel Approaches for the Treatment of Patients with Richter's Syndrome. Curr Treat Options Oncol 2022; 23:526-542. [PMID: 35294723 PMCID: PMC8989931 DOI: 10.1007/s11864-022-00973-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/19/2022]
Abstract
In the last 10–15 years, the way to treat cancers has dramatically changed towards precision medicine approaches. These treatment options are mainly based on selective targeting against signaling pathways critical for or detrimentally activated in cancer cells in cancer cells, as well as exploiting molecules that are specifically expressed on neoplastic cells, also known as tumor-associated antigens. These considerations hold true also in the hematological field where a plethora of novel targeted agents have reached patients’ bedside, significantly improving clinical responses. Chronic lymphocytic leukemia (CLL) is an example of how targeted therapies, such as BTK, PI3K, or Bcl-2 inhibitors as well as anti-CD20 antibodies, have improved patients’ management, even when adopted as frontline treatment. However, these advancements do not apply to Richter’s syndrome (RS), the transformation of CLL into a very aggressive and fatal lymphoma, occurring in 2–10% of patients. RS is usually a fast-growing lymphoma of the diffuse large B cell or the Hodgkin’s variant, with a dismal prognosis. Despite advancements in depicting and understanding the genetic background of RS and its pathogenesis, no significant clinical results have been registered. In the last couple of years, several studies have started to investigate the impact of novel drugs or drug combinations and some of them have opened for clinical trials, currently in phase I or II, whose results will be soon available. This review will present an overview of current and most recent therapeutic options in RS, discussing also how results coming from xenograft models may help in designing and identifying novel treatment opportunities to overcome the lack of effective therapies.
Collapse
MESH Headings
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Prognosis
Collapse
Affiliation(s)
- Andrea Iannello
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
| | - Silvia Deaglio
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
| | - Tiziana Vaisitti
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
| |
Collapse
|
34
|
Fischer K, Al-Sawaf O. Acalabrutinib monotherapy in patients with Richter transformation. LANCET HAEMATOLOGY 2021; 8:e868-e870. [PMID: 34735861 DOI: 10.1016/s2352-3026(21)00334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Kirsten Fischer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen, Bonn, Cologne, and Duesseldorf (CIO), Aachen Germany.
| | - Othman Al-Sawaf
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Internal Medicine, German CLL Study Group, Center for Integrated Oncology Aachen, Bonn, Cologne, and Duesseldorf (CIO), Aachen Germany; The Francis Crick Institute, London, UK; UCL Cancer Institute, University College London, London, UK
| |
Collapse
|