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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.
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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
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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.
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2
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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.
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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
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3
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Nato Y, Nagaharu K, Inoue K, Yabu K, Sawaki A, Shiotani T, Kageyama Y, Tanaka K, Ohshima K, Miyashita H. An experience with ibrutinib monotherapy for Richter's syndrome isolated in the central nervous system. J Clin Exp Hematop 2022; 62:238-241. [PMID: 36436931 PMCID: PMC9898719 DOI: 10.3960/jslrt.22017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Richter's syndrome (RS) of the central nervous system (CNS) is known to have an extremely poor prognosis. Ibrutinib has been reported to have some activity in patients with RS, despite its poor prognosis. Although ibrutinib crosses the blood-brain barrier, its efficacy in RS patients with CNS involvement remains unknown. Here, we report a case of RS isolated in the CNS that was confirmed to be clonally related to chronic lymphocytic leukemia (CLL) by immunoglobulin heavy chain gene analysis. Although the median survival of patients with RS clonally related to CLL was significantly shorter than that of patients with RS clonally unrelated to CLL, the patient received ibrutinib monotherapy without experiencing any significant adverse events, and the disease remained stable with ibrutinib until 6 weeks later. Following whole-brain radiation therapy (40 Gy in 20 fractions) with dexamethasone, the patient has survived for five months after diagnosis. Thus, ibrutinib may be a safe and effective therapeutic option for patients with RS and CNS involvement.
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Affiliation(s)
- Yuma Nato
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Keiki Nagaharu
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Kanako Inoue
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Kodai Yabu
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Akihiko Sawaki
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Takuya Shiotani
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Yuki Kageyama
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Ken Tanaka
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Hiroyuki Miyashita
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
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4
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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.
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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.
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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.
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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
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7
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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.
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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
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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
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Synergistic efficacy of the dual PI3K-δ/γ inhibitor duvelisib with the Bcl-2 inhibitor venetoclax in Richter syndrome PDX models. Blood 2021; 137:3378-3389. [PMID: 33786583 DOI: 10.1182/blood.2020010187] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022] Open
Abstract
A small subset of cases of chronic lymphocytic leukemia undergoes transformation to diffuse large B-cell lymphoma, Richter syndrome (RS), which is associated with a poor prognosis. Conventional chemotherapy results in limited responses, underlining the need for novel therapeutic strategies. Here, we investigate the ex vivo and in vivo efficacy of the dual phosphatidylinositol 3-kinase-δ/γ (PI3K-δ/γ) inhibitor duvelisib (Duv) and the Bcl-2 inhibitor venetoclax (Ven) using 4 different RS patient-derived xenograft (PDX) models. Ex vivo exposure of RS cells to Duv, Ven, or their combination results in variable apoptotic responses, in line with the expression levels of target proteins. Although RS1316, IP867/17, and RS9737 cells express PI3K-δ, PI3K-γ, and Bcl-2 and respond to the drugs, RS1050 cells, expressing very low levels of PI3K-γ and lacking Bcl-2, are fully resistant. Moreover, the combination of these drugs is more effective than each agent alone. When tested in vivo, RS1316 and IP867/17 show the best tumor growth inhibition responses, with the Duv/Ven combination leading to complete remission at the end of treatment. The synergistic effect of Duv and Ven relies on the crosstalk between PI3K and apoptotic pathways occurring at the GSK3β level. Indeed, inhibition of PI3K signaling by Duv results in GSK3β activation, leading to ubiquitination and subsequent degradation of both c-Myc and Mcl-1, making RS cells more sensitive to Bcl-2 inhibition by Ven. This work provides, for the first time, a proof of concept of the efficacy of dual targeting of PI3K-δ/γ and Bcl-2 in RS and providing an opening for a Duv/Ven combination for these patients. Clinical studies in aggressive lymphomas, including RS, are under way. This trial was registered at www.clinicaltrials.gov as #NCT03892044.
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Abstract
PURPOSE OF REVIEW Richter syndrome (RS) is an uncommon but aggressive evolution of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). RS is an unmet clinical need in the field of CLL. Recent advances in understanding the biology of this condition provide the rationale for testing new therapeutic concepts in order to improve the outcome of patients developing RS, which is so far poor. In this review, we summarize disease characteristics and available therapeutic options for RS. RECENT FINDINGS Current regimens with novel agents in monotherapy have shown little impact on survival. Nevertheless, the better reported outcome for RS has been achieved with the combination of chemo-immunotherapy with a novel agent, confirming the synergistic effect of the approaches. Still, the frailty of this population may impose a less toxic management leaving most patients with no reasonable therapeutic option. Treatment options for RS need to be further expanded. Preclinical models in current development may allow to explore actionable pathways and identify new drug targeted combinations.
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Affiliation(s)
- Adalgisa Condoluci
- Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland
| | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
- Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.
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10
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Abstract
Patients with chronic lymphocytic leukemia can be divided into three categories: those who are minimally affected by the problem, often never requiring therapy; those that initially follow an indolent course but subsequently progress and require therapy; and those that from the point of diagnosis exhibit an aggressive disease necessitating treatment. Likewise, such patients pass through three phases: development of the disease, diagnosis, and need for therapy. Finally, the leukemic clones of all patients appear to require continuous input from the exterior, most often through membrane receptors, to allow them to survive and grow. This review is presented according to the temporal course that the disease follows, focusing on those external influences from the tissue microenvironment (TME) that support the time lines as well as those internal influences that are inherited or develop as genetic and epigenetic changes occurring over the time line. Regarding the former, special emphasis is placed on the input provided via the B-cell receptor for antigen and the C-X-C-motif chemokine receptor-4 and the therapeutic agents that block these inputs. Regarding the latter, prominence is laid upon inherited susceptibility genes and the genetic and epigenetic abnormalities that lead to the developmental and progression of the disease.
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Affiliation(s)
- Nicholas Chiorazzi
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York 11030, USA
| | - Shih-Shih Chen
- The Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York 11030, USA
| | - Kanti R. Rai
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York 11549, USA
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Safety and activity of ibrutinib in combination with nivolumab in patients with relapsed non-Hodgkin lymphoma or chronic lymphocytic leukaemia: a phase 1/2a study. LANCET HAEMATOLOGY 2019; 6:e67-e78. [DOI: 10.1016/s2352-3026(18)30217-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 12/14/2022]
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Awan FT, Thirman MJ, Patel-Donnelly D, Assouline S, Rao AV, Ye W, Hill B, Sharman JP. Entospletinib monotherapy in patients with relapsed or refractory chronic lymphocytic leukemia previously treated with B-cell receptor inhibitors: results of a phase 2 study. Leuk Lymphoma 2019; 60:1972-1977. [PMID: 30633573 DOI: 10.1080/10428194.2018.1562180] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Entospletinib (GS-9973), an oral, selective inhibitor of spleen tyrosine kinase (SYK), was evaluated as monotherapy in this multicenter, phase 2 study (NCT01799889) of 49 patients with relapsed or refractory chronic lymphocytic leukemia (CLL), including those with Richter's transformation (RT), who had received prior therapy with a B-cell receptor (BCR) inhibitor. Patients were treated with entospletinib 400 mg BID as the starting dose. Sixteen patients achieved partial response and 21 had stable disease. The overall response rate was 32.7% (95% confidence interval [CI]: 21.7-45.3%). The median progression-free survival (PFS) was 5.6 (95% CI: 3.7-8.3) months. Twenty-one (of 43) patients (48.8%) experienced nodal response. Adverse events (AEs) occurred in all patients; most commonly fatigue, diarrhea, and anemia. Entospletinib monotherapy has clinical activity for patients with CLL and RT who have relapsed following therapy with BCR inhibitors.
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Affiliation(s)
- Farrukh T Awan
- a Division of Hematology , The Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Michael J Thirman
- b Department of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | | | - Sarit Assouline
- d Department of Oncology , McGill University Medical School , Montreal , QC , Canada
| | - Arati V Rao
- e Gilead Sciences, Inc. , Foster City , CA , USA
| | - Wei Ye
- e Gilead Sciences, Inc. , Foster City , CA , USA
| | - Brian Hill
- f Department of Hematology and Oncology, Cleveland Clinic , Cleveland , OH , USA
| | - Jeff P Sharman
- g Willamette Valley Cancer Institute and Research Center and US Oncology Research , Springfield , OR , USA
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13
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Allan JN, Furman RR. Current trends in the management of Richter's syndrome. Int J Hematol Oncol 2019; 7:IJH09. [PMID: 30651968 PMCID: PMC6331753 DOI: 10.2217/ijh-2018-0010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/21/2018] [Indexed: 12/16/2022] Open
Abstract
Richter's syndrome (RS) is a life-threatening complication of chronic lymphocytic leukemia (CLL). While previous research has increased our knowledge on the distinct evolutionary patterns of RS and provided a deeper understanding of the risk factors and molecular events predisposing to transformation, there remain few targetable aberrations and treatment is largely ineffective. The ability to obtain deeper remissions, without selecting for deletion 17p, by using novel B-cell receptor (BCR) antagonists and bcl2 inhibition might lead to a decrease in the incidence of RS, but these agents have done little to significantly change outcomes when incorporated into treatment regimens for RS. In this review we highlight the current landscape of molecular lesions specific to RS, review the data on historical treatment options, and look to the horizon for potential opportunities in the future.
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Affiliation(s)
- John N Allan
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Richard R Furman
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
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14
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Thebo U, Millett RL, Elkon J, Haroun F. Two distinct histological Richter's transformations 23 years apart in a patient with chronic lymphocytic leukaemia. BMJ Case Rep 2018; 2018:bcr-2018-225893. [PMID: 30301728 DOI: 10.1136/bcr-2018-225893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
A 53-year-old man with a 1-year history of chronic lymphocytic leukaemia (CLL) presented with a left bicep mass. Biopsy and staging workup revealed Richter's transformation (RT) Ann Arbor stage 1E diffuse large B-cell lymphoma in the bicep. The patient was treated with combination chemotherapy with cyclophosphamide, doxorubicin, Vincristine and prednisone followed by site radiation and did well thereafter. His CLL progressed and required treatment on two more occasions 11 and 18 years after his initial diagnosis with fludarabine, Cytoxan and Rituxan and then with bendamustine and rituximab. 23 years after initial presentation, he developed diffuse lymphadenopathy and B-symptoms. A biopsy of an enlarged cervical lymph node demonstrated only CLL for which he was started on ibrutinib. Treatment was shortly discontinued thereafter due to intolerance and worsening symptoms. A second biopsy was performed which revealed concurrent CLL and Hodgkin's lymphoma representing a second and histologically distinct RT.
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Affiliation(s)
- Umera Thebo
- Hematology and Oncology, George Washington University, Washington, DC, USA
| | - Ralph Linwood Millett
- Department of Hematology and Oncology, George Washington University, Washington, DC, USA
| | - Jacob Elkon
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Faysal Haroun
- Hematology and Oncology, George Washington University, Washington, DC, USA
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15
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Taneja A, Jones J, Pittaluga S, Maric I, Farooqui M, Ahn IE, Wiestner A, Sun C. Richter transformation to Hodgkin lymphoma on Bruton's tyrosine kinase inhibitor therapy. Leuk Lymphoma 2018; 60:519-522. [PMID: 29978754 DOI: 10.1080/10428194.2018.1480775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Alankrita Taneja
- a Hematology Branch , National Heart, Lung, and Blood Institute, National Institutes of Health , Bethesda , MD , USA
| | - Jade Jones
- b Division of Cancer Medicine , MD Anderson Cancer Center , Houston , TX , USA
| | - Stefania Pittaluga
- c Laboratory of Pathology , National Cancer Institute, National Institutes of Health , Bethesda , MD , USA
| | - Irina Maric
- d Department of Laboratory Medicine , Clinical Center National Institutes of Health , Bethesda , MD , USA
| | - Mohammed Farooqui
- a Hematology Branch , National Heart, Lung, and Blood Institute, National Institutes of Health , Bethesda , MD , USA
| | - Inhye E Ahn
- a Hematology Branch , National Heart, Lung, and Blood Institute, National Institutes of Health , Bethesda , MD , USA
| | - Adrian Wiestner
- a Hematology Branch , National Heart, Lung, and Blood Institute, National Institutes of Health , Bethesda , MD , USA
| | - Clare Sun
- a Hematology Branch , National Heart, Lung, and Blood Institute, National Institutes of Health , Bethesda , MD , USA
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16
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Khan M, Siddiqi R, Thompson PA. Approach to Richter transformation of chronic lymphocytic leukemia in the era of novel therapies. Ann Hematol 2017; 97:1-15. [DOI: 10.1007/s00277-017-3149-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 10/03/2017] [Indexed: 12/22/2022]
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17
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Master S, Leary C, Takalkar A, Coltelingam J, Mansour R, Mills GM, Koshy N. Successful Treatment of Richter Transformation with Ibrutinib in a Patient with Chronic Lymphocytic Leukemia following Allogeneic Hematopoietic Stem Cell Transplant. Case Rep Oncol 2017; 10:534-541. [PMID: 28690529 PMCID: PMC5498945 DOI: 10.1159/000477338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/08/2017] [Indexed: 12/23/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) who progress to Richter transformation (RT) have a poor prognosis. Multi-agent chemotherapy regimens do not have good response rates. There are few case reports on the use of ibrutinib in RT. Here, we present a patient who was heavily pretreated for CLL, including allogeneic stem cell transplant, and progressed to RT. She had a mixed response to multi-agent chemotherapy and was started on ibrutinib. She had a complete response for 16 months on single-agent ibrutinib with minimal toxicity.
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Affiliation(s)
- Samip Master
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Cheri Leary
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Amol Takalkar
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - James Coltelingam
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Richard Mansour
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Glenn M Mills
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nebu Koshy
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
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18
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Abstract
The term Richter syndrome (RS) indicates the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma. RS is a rare complication with an aggressive clinical course, bearing an unfavorable prognosis. In the majority of cases, CLL transforms into RS as diffuse large B cell lymphoma (DLBCL), and a clonal relation between the two processes can be found. However, clonally unrelated RS can occur and transformations to other histologies beside DLBCL have been described. Recent data have shed some light on genetic characteristics that can influence and drive the transformation from CLL to RS. This molecular information has not been translated yet into significant treatment advances, and currently the therapy regimens for RS continue to rely on intensive chemotherapy combinations followed by stem cell transplant in suitable candidates. Based on the rapid pace of discoveries in the field of hematological malignancies and on the recent revolution in the therapeutic landscape for CLL and B cell lymphomas, new therapeutic options for RS might be available in the upcoming years.
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Affiliation(s)
- Candida Vitale
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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19
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Agbay RLMC, Jain N, Loghavi S, Medeiros LJ, Khoury JD. Histologic transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma. Am J Hematol 2016; 91:1036-43. [PMID: 27414262 DOI: 10.1002/ajh.24473] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 07/05/2016] [Accepted: 07/12/2016] [Indexed: 12/20/2022]
Abstract
Although generally considered a clinically indolent neoplasm, CLL/SLL may undergo transformation to a clinically aggressive lymphoma. The most common form of transformation, to DLBCL, is also known as Richter syndrome. Transformation determines the course of the disease and is associated with unfavorable patient outcome. Precise detection of transformation and identification of predictive biomarkers and specific molecular pathways implicated in the pathobiology of transformation in CLL/SLL will enable personalized therapeutic approach and provide potential avenues for improving the clinical outcome of patients. In this review, we present an overview of the pathologic features, risk factors, and pathogenic mechanisms of CLL/SLL transformation. Am. J. Hematol. 91:1036-1043, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rose Lou Marie C. Agbay
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Nitin Jain
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Sanam Loghavi
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - L. Jeffrey Medeiros
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joseph D. Khoury
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
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20
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Ayers EC, Mato AR. Richter's Transformation in the Era of Kinase Inhibitor Therapy: A Review. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 17:1-6. [PMID: 27707629 DOI: 10.1016/j.clml.2016.08.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/19/2016] [Accepted: 08/26/2016] [Indexed: 12/16/2022]
Abstract
Richter's transformation (RT) is the transformation of chronic lymphocytic leukemia (CLL) into rapidly progressive B-cell lymphoma. This disease has long been recognized as a difficult-to-treat illness with poor survival outcomes. Although the incidence of RT has been well documented in previous studies, less is understood in the era of novel therapeutics, such as kinase inhibitors (KIs). The present review discusses the current risk factors, incidence, and outcomes of patients with RT in the modern era of KI therapy. Although the outcomes remain poor for RT patients after KI therapy, the most up-to-date studies have shown no increased incidence of RT in this patient population. Additionally, the present review reports the outcomes from the most recent data on novel therapies under investigation for patients with RT.
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Affiliation(s)
- Emily C Ayers
- Center for CLL, Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA
| | - Anthony R Mato
- Center for CLL, Division of Hematology/Oncology, Perelman Center for Advanced Medicine, Philadelphia, PA.
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21
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22
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Chan KL, Lokan J, Tam CS, Lew TE, Prince HM. Central nervous system immune reconstitution inflammatory syndrome after ibrutinib therapy for Richter transformation. Leuk Lymphoma 2016; 58:207-210. [PMID: 27326828 DOI: 10.1080/10428194.2016.1179298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Kah-Lok Chan
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia
| | - Julie Lokan
- b Department of Pathology , Austin Hospital , Melbourne , Australia
| | - Constantine S Tam
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia.,c The University of Melbourne , Melbourne , Australia
| | | | - H Miles Prince
- a Department of Haematology , Peter MacCallum Cancer Centre , Melbourne , Australia.,c The University of Melbourne , Melbourne , Australia
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