Low and medium dose spleen radiation therapy are able to induce long-term responses in splenic lymphoma with villous lymphocytes

Chemotherapy-Free Management of Follicular and Marginal Zone Lymphoma

Many patients with follicular (FL) or marginal zone lymphoma (MZL) are not eligible to receive immunochemotherapy due to advanced age or comorbidities. Recent innovations in the treatment of these indolent lymphomas provide options for multiple lines of chemotherapy-free management. More research is needed to determine which older patients are best served by a chemotherapy-free approach in the context of geriatric vulnerabilities. In the first line, regardless of disease burden, rituximab monotherapy can provide high rates of disease control with minimal toxicity, while judicious use of brief maintenance extends the duration of response. Radioimmunotherapy using ibritumomab tiuxetan is an effective and safe post-rituximab consolidation for older patients who have <25% bone marrow involvement. The combination of rituximab and lenalidomide, although “chemotherapy-free”, does not improve tolerability over immunochemotherapy. However, studies support lower doses and shorter duration of lenalidomide exposure as a means to improve safety without materially compromising efficacy for older individuals. Extranodal MZL can often be effectively controlled with low-dose radiation therapy, and splenic MZL has excellent outcomes with rituximab monotherapy. For many patients with relapsed FL/MZL, simple retreatment with anti-CD20 antibodies will prove sufficient. Other currently available options for relapsed/refractory disease include ibritumomab tiuxetan, lenalidomide with rituximab, umbralisib as a potentially less toxic PI3K inhibitor, ibrutinib (for MZL), and tazemetostat (for FL, especially with EZH2 mutation). Emerging data with novel forms of immunotherapy (antibody-drug conjugates like polatuzumab vedotin or loncastuximab tesirine; T-cell-engaging bispecific antibodies like mosunetuzumab or epcoritamab; and chimeric antigen receptor CAR T-cells like axicabtagene ciloleucel) suggest that immune-directed approaches can produce very high and potentially durable responses in FL/MZL with limited toxicities, further obviating the need for chemotherapy.

How we treat mature B-cell neoplasms (indolent B-cell lymphomas)

Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.

Splenic marginal zone lymphoma: a literature review of diagnostic and therapeutic challenges

Splenic marginal zone lymphoma (SMZL) is a low-grade B-cell non-Hodgkin's lymphoma characterized by massive splenomegaly, moderate lymphocytosis with or without villous lymphocytes, rare involvement of peripheral lymph nodes and indolent clinical course. As a rare disease, with no randomized prospective trials, there is no standard of care for SMZL so far. Splenectomy has been done for many years as an attempt to control disease, but nowadays it has not been encouraged as first line because of new advances in therapy as rituximab, that are as effective with minimal toxicity. Facing these controversies, this review highlights advances in the literature regarding diagnosis, prognostic factors, treatment indications and therapeutic options.

Low-dose palliative splenic irradiation in haematolymphoid malignancy

Patients are treated with palliative splenic irradiation (SI) to relieve pain, volume effects and the clinical consequences of hypersplenism. The case records of 19 patients treated with palliative SI at our centre, from April 2003 to November 2004, were reviewed. Twenty-two courses of SI were identified. The radiation doses delivered ranged from 150 to 800 cGy (median 450 cGy). The fraction sizes ranged from 25 to 100 cGy. Parallel-opposed anteroposterior-posteroanterior portals were the most common field arrangement. The target volume was reduced in 18 out of 22 courses. The percentage of field reduction ranged from 0 to 59.57% (mean 24.82%). Twelve of 14 courses were successful in achieving symptom palliation. Of the six patients who received SI for a combination of splenic symptoms and abnormal blood tests, five had symptomatic palliation but only one patient responded haematologically. Of two patients who were started on palliative SI for abnormal haematology alone, only one responded. In summary, 17 of 20 (85%) courses of SI initiated for symptom control resulted in effective palliation. Only two of eight (25%) courses of SI started for abnormal blood counts produced a desired response. To conclude, SI offers an effective and well-tolerated palliative treatment option.

Outline for writing an article for current treatment options in oncology: splenic lymphoma with villous lymphocytes

Two subtypes of splenic marginal zone lymphoma (SMZL) are identified in the World Health Organization (WHO) classification: SMZL without villous lymphocytes and SMZL with villous lymphocytes in the peripheral blood (SLVL). SLVL is a rare leukemic and indolent B-cell chronic lymphoproliferative disorder (B-CLPD) that we have to differentiate from hairy cell leukemia (HCL), B prolymphocytic leukemia (B-PLL) and follicular lymphoma (FL). Morphological examination associated with immunophenotyping is, in most cases, likely to distinguish these CD5 negative entities. However, the diagnosis can be difficult to make on morphological criteria, especially in patients without absolute lymphocytosis. Based on histologic, cytogenetic and molecular studies, SLVL emerges as a distinct entity. SLVL has a relatively clinical benign course but a few patients could require treatment, because of a symptomatic splenomegaly and/or a severe cytopenia. In symptomatic patients HCV negative, the frontline treatment remains questionable. Splenectomy, regarded as the most effective treatment, could be required for diagnostic purposes: however, relapse occur in 30% of cases. Fludarabine (FDR), a purine analogue and deoxycoformycin (DCF) can induce a maintained response in a substantial proportion of patients with SLVL and could be used as a first line treatment. In HCV + SLVL patients, antiviral treatment using alpha interferon and ribavirin can induce regression of SLVL.

Marginal Zone Lymphomas: Management of Nodal, Splenic, and MALT NHL

Marginal zone lymphomas are indolent B-cell lymphomas that originate from the marginal zone of B-cell follicles. For several subtypes, the initiation of disease appears to be a consequence of chronic infection and/ or inflammation. While the initial lymphoid hyperplasia is driven by physiologic antigenic stimulation, additional oncogenic events, such as chromosomal translocations leading to constitutive activation of signaling pathways, occur during the progression of disease that ultimately result in antigen-independent lymphoproliferation. Despite having a common origin in the marginal zone of the B-cell follicle, there are distinct clinical and molecular characteristics of marginal zone lymphomas originating at different anatomic sites. As such, marginal zone–derived lymphomas are currently categorized by the World Health Organization (WHO) into those originating in the spleen (splenic marginal zone lymphoma), extranodal mucosa-associated lymphoid tissue (MALT lymphoma), or lymph node (nodal marginal zone lymphoma).

Splenic marginal zone lymphoma

Splenic marginal zone lymphoma (SMZL) is an indolent B cell malignancy usually involving spleen, bone marrow and blood. The disease presents as an incidental finding or with symptoms of splenic enlargement or anaemia. Diagnosis is based on a combination of lymphocyte morphology, immunophenotype and marrow and /or splenic histology. There is no genetic abnormality specific for SMZL, but deletions of chromosome 7q are the commonest abnormality and are found in 30-50% of cases. SMZL cells may have either mutated or unmutated immunoglobulin variable region genes and probably arise from different subsets of splenic marginal zone B cells. Prognostic factors are poorly defined and only loss or mutation of the p53 gene is consistently associated with a poor outcome. Therapeutic options include splenectomy, splenic irradiation, alkylating agents, purine analogues or anti CD20 antibody. The median survival is 10-13 years and most disease-related deaths are associated with transformation to diffuse large cell lymphoma.

Low dose 2-CdA schedule activity in splenic marginal zone lymphomas

Splenic Marginal Zone Lymphoma (SMZL) is a rare clinicopathological entity among marginal zone lymphomas. SMZL is an indolent lymphoma usually treated by splenectomy. A subset of patients is characterized by a more aggressive clinical course and poor prognosis. Treatment of these cases and second-line therapy for relapsed patients have not been yet identified. We report 10 cases treated with cladribrine (5 mg/m(2)/week) for six courses. Six patients (60%) achieved partial response, two patients (20%) achieved a complete response and the two remaining patients did not respond and died as a result of progression of the disease. The treatment was well tolerated. A total of 60% of the patients had an overall survival rate of 48 months and 24 months progression-free-survival was achieved by 37% with a median time of progression-free-survival of 17 months. Interestingly, in addition to a relevant percentage of hematological remission, some patients also experienced a molecular remission. We conclude that this treatment is safe and well tolerated and is able to induce a substantial number of responses. Our results suggest that this schedule is well tolerated and could be an useful alternative to splenectomy.

Splenic marginal zone lymphoma

Splenic marginal zone lymphoma (SMZL) is a specific low-grade small B-cell lymphoma that is incorporated in the World Health Organization classification. Characteristic features are splenomegaly, moderate lymphocytosis with villous morphology, intrasinusoidal pattern of involvement of various organs, especially bone marrow, and relative indolent course. Tumor progression with increase of blastic forms and aggressive behavior are observed in a minority of patients. Molecular and cytogenetic studies have shown heterogeneous results probably because of the lack of standardized diagnostic criteria. To date, no definitive therapy has been established. Therapeutic options include treatment abstention, splenectomy, splenic irradiation, and chemotherapy.

Clinical indications and biological mechanisms of splenic irradiation in chronic leukaemias and myeloproliferative disorders

Splenic irradiation (SI) was the first efficient treatment for chronic leukaemia, but with the emergence of effective drugs its use has been more and more restricted to advanced cases presenting with splenomegaly. But in selected patients who are not responsive or not suitable to drug treatment, SI may offer still an effective, low toxic and cost-effective palliative modality. Eight studies of SI in chronic lymphatic leukaemia (CLL) including 198 patients, six reports about SI in prolymphocytic leukaemia (PLL), including 18 patients, one study and six case reports about SI in hairy cell leukaemia (HCL) and nine studies about SI in myeloproliferative disorders has been analyzed. In CLL, symptoms of splenomegaly have been improved in 50-87% of all patients with overall doses between 4 and 10 Gy in mostly 1-Gy fractions. PLL seems to be more resistant to SI with a median response rate of 66%. Casuistic reports described also efficacy of SI in HCL patients using similar radiation schedules. Symptomatic relief is also provided by SI in myeloproliferative disorders using lower overall doses between 1 and 9 Gy with small single fractions of 0.25 Gy (median). Acute toxicity was low in lymphoid disorders, but higher in myeloproliferative disorders with severe cytopenia in 10-30% of all cases, indicating the need for a cautious fractionation schedule. Interestingly, even complete systemic remissions after SI in all types of lymphoproliferative disorders have been described. Different mechanisms underlying SI such as direct cell kill, immune modulation via changes in lymphocyte subsets or cytokine induction or "radiotherapeutic" splenectomy with high doses are discussed.