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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.
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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
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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
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2
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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.
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Affiliation(s)
- Toby A. Eyre
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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3
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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.
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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
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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.
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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..
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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.
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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
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6
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Briski R, Taylor J. Treatment of Richter Transformation of Chronic Lymphocytic Leukemia in the Modern Era. Cancers (Basel) 2023; 15:cancers15061857. [PMID: 36980742 PMCID: PMC10047346 DOI: 10.3390/cancers15061857] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Richter Transformation (RT) refers to the development of an aggressive lymphoma in the setting of chronic lymphocytic leukemia (CLL). While many variants of RT are recognized, diffuse large B-cell lymphoma (RT-DLBCL) is the most common (80%), followed by Hodgkin’s lymphoma (RT-HL, 19%). Diagnosis is based upon histologic evaluation of clinically suspicious lymph nodes. Positron emission tomography (PET) may be used to select the node of interest for biopsy. Although clonality testing is not a prerequisite of RT diagnosis, it has significant implications for survival. Clonally related DLBCL carries the worst prognosis with a median overall survival (OS) of less than one year in the era of combination chemotherapies with or without anti-CD20 antibodies. Prognosis has improved with the use of stem cell transplant and newer agents such as targeted therapy and newer forms of immunotherapy. Consideration of a clinical trial is encouraged. This review describes our current understanding of RT and focuses on treatment of RT-DLBCL, including clinical trials in progress and new therapies in development. We also report an illustrative example of a patient with clonally related DLBCL who survived two years after diagnosis without the use of combination chemotherapy.
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Affiliation(s)
- Robert Briski
- M.D. Anderson Cancer Center, Houston, TX 77030, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence:
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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.
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8
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Eyre TA, Riches JC, Patten PEM, Walewska R, Marr H, Follows G, Hillmen P, Schuh AH. Richter transformation of chronic lymphocytic leukaemia: a British Society for Haematology Good Practice Paper. Br J Haematol 2021; 196:864-870. [PMID: 34607388 DOI: 10.1111/bjh.17882] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/12/2021] [Accepted: 09/23/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Toby A Eyre
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John C Riches
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Piers E M Patten
- Comprehensive Cancer Centre, School of Cancer and Pharmaceutical Sciences, King's College London, London, UK.,Department of Haematology, King's College Hospital, London, UK
| | - Renata Walewska
- Department of Haematology, University Hospitals Dorset, Bournemouth, UK
| | - Helen Marr
- Northern Centre for Cancer Care, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | | | - Peter Hillmen
- St. James's Institute of Oncology, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Anna H Schuh
- Department of Haematology, Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Oncology, University of Oxford, John Radcliffe Hospital, Oxford, UK
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9
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Croizier C, Guièze R. [Richter Syndrome: Diagnostic and Therapeutic Management]. Bull Cancer 2021; 108:521-527. [PMID: 33896586 DOI: 10.1016/j.bulcan.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/18/2021] [Indexed: 10/21/2022]
Abstract
Richter syndrome (RS) is defined as the occurrence of an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL) and rarely Hodgkin lymphoma (HL), in a patient with prior or concomitant chronic lymphocytic leukemia (CLL). RS is estimated to occur in 0.5-1 % per year and is associated with adverse outcome. In the vast majority of patients (80 %), RS is clonally related to the prior CLL. Those with unrelated RS appear to have better outcome. The therapeutic approach is based on those of de novo DLBCL or HL. However, even with modern immunochemotherapy regimens, response rate remains low. In eligible patients with related RS, a consolidation by autologous or allogeneic stem-cell transplantation must be proposed. Combinations including therapies targeting BCR or BCL2 and effective in CLL are currently being evaluated in RS. Novels immunotherapies could be promising approaches based on preliminary results.
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Affiliation(s)
- Carolyne Croizier
- Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Estaing, 1, place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France.
| | - Romain Guièze
- Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Estaing, 1, place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France; EA 7453, CHELTER, Université Clermont Auvergne, CHU Estaing, Hématologie Biologique, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
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10
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Verzicco I, Regolisti G, Quaini F, Bocchi P, Brusasco I, Ferrari M, Passeri G, Cannone V, Coghi P, Fiaccadori E, Vignali A, Volpi R, Cabassi A. Electrolyte Disorders Induced by Antineoplastic Drugs. Front Oncol 2020; 10:779. [PMID: 32509580 PMCID: PMC7248368 DOI: 10.3389/fonc.2020.00779] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 04/22/2020] [Indexed: 12/23/2022] Open
Abstract
The use of antineoplastic drugs has a central role in treatment of patients affected by cancer but is often associated with numerous electrolyte derangements which, in many cases, could represent life-threatening conditions. In fact, while several anti-cancer agents can interfere with kidney function leading to acute kidney injury, proteinuria, and hypertension, in many cases alterations of electrolyte tubular handling and water balance occur. This review summarizes the mechanisms underlying the disturbances of sodium, potassium, magnesium, calcium, and phosphate metabolism during anti-cancer treatment. Platinum compounds are associated with sodium, potassium, and magnesium derangements while alkylating agents and Vinca alkaloids with hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion (SIADH). Novel anti-neoplastic agents, such as targeted therapies (monoclonal antibodies, tyrosine kinase inhibitors, immunomodulators, mammalian target of rapamycin), can induce SIADH-related hyponatremia and, less frequently, urinary sodium loss. The blockade of epidermal growth factor receptor (EGFR) by anti-EGFR antibodies can result in clinically significant magnesium and potassium losses. Finally, the tumor lysis syndrome is associated with hyperphosphatemia, hypocalcemia and hyperkalemia, all of which represent serious complications of chemotherapy. Thus, clinicians should be aware of these side effects of antineoplastic drugs, in order to set out preventive measures and start appropriate treatments.
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Affiliation(s)
- Ignazio Verzicco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giuseppe Regolisti
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Federico Quaini
- Ematologia e Oncologia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Bocchi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Irene Brusasco
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Massimiliano Ferrari
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Giovanni Passeri
- Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Valentina Cannone
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Pietro Coghi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Enrico Fiaccadori
- Unità di Ricerca sulla Insufficienza Renale Acuta e Cronica, Unità di Nefrologia, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Alessandro Vignali
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Riccardo Volpi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy.,Unità di Endocrinologia e Malattie Osteometaboliche, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
| | - Aderville Cabassi
- Unità di Ricerca Cardiorenale, Clinica e Terapia Medica, Dipartimento di Medicina e Chirurgia (DIMEC), University of Parma, Parma, Italy
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PD-1 Expression in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) and Large B-cell Richter Transformation (DLBCL-RT): A Characteristic Feature of DLBCL-RT and Potential Surrogate Marker for Clonal Relatedness. Am J Surg Pathol 2019; 42:843-854. [PMID: 29762141 DOI: 10.1097/pas.0000000000001077] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a low-grade B-cell neoplasm and ∼2% to 9% patients develop an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (Richter transformation, DLBCL-RT). Programmed death-1 (PD-1) pathway plays a crucial role in tumor host immunity evasion and its blockade has emerged as an effective anti-cancer immunotherapy. PD-L1 and PD-1 expression has shown predictive value in anti-PD cancer immunotherapy; however, it has not been well documented in CLL/SLL and DLBCL-RT. We evaluated PD-1 and PD-L1 expression by immunohistochemistry in 39 CLL/SLL, 15 DLBCL-RT, and 26 other DLBCL. In CLL/SLL, neoplastic B-cell PD-1 expression was weak and restricted to prolymphocytes/paraimmunoblasts within proliferation centers (PCs) and accentuated PCs of all sizes. Neoplastic B-cell PD-1 expression was highly prevalent and demonstrated increased intensity in DLBCL-RT, but in contrast was only rarely seen in other DLBCL (12/15 vs. 1/26; P<0.0001). An excellent correlation (90% concordance) was observed between neoplastic B-cell PD-1 immunohistochemistry positivity and molecularly defined CLL/SLL clonal relatedness in DLBCL-RT. PD-L1 expression was observed on the neoplastic B cells in rare DLBCL-RT and other DLBCL cases (1/15 vs. 1/26; P>0.05) as well as background histiocytes and dendritic cells. Overall survival of DLBCL-RT was significantly inferior to that of the other DLBCL (median, 16.9 vs. 106.1 mo; P=0.002). Our findings suggest a biological continuum from prolymphocytes/paraimmunoblasts in CLL/SLL PCs to the neoplastic B-cells in DLBCL-RT. The characteristic PD-1 expression in DLBCL-RT makes it a potential surrogate marker for determining clonal relatedness to CLL/SLL, which may have important prognostic and therapeutic implications.
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13
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Mato AR, Wierda WG, Davids MS, Cheson BD, Coutre SE, Choi M, Furman RR, Heffner L, Barr PM, Eradat H, Ford SM, Zhou L, Verdugo M, Humerickhouse RA, Potluri J, Byrd JC. Utility of positron emission tomography-computed tomography in patients with chronic lymphocytic leukemia following B-cell receptor pathway inhibitor therapy. Haematologica 2019; 104:2258-2264. [PMID: 30923097 PMCID: PMC6821597 DOI: 10.3324/haematol.2018.207068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 03/20/2019] [Indexed: 12/17/2022] Open
Abstract
The utility of positron emission tomography-computed tomography (PET-CT) in distinguishing Richter’s transformation versus chronic lymphocytic leukemia (CLL) progression after ibrutinib and/or idelalisib was assessed in a post hoc analysis of a phase II study of venetoclax. Patients underwent PET-CT at screening and were not enrolled/treated if Richter’s transformation was confirmed pathologically. Of 167 patients screened, 57 met criteria for biopsy after PET-CT. Of 35 patients who underwent biopsy, eight had Richter’s transformation, two had another malignancy, and 25 had CLL. A PET-CT maximum standardized uptake value (SUVmax) ≥10 had 71% sensitivity and 50% specificity for detecting Richter’s transformation [Odds Ratio (OR): 2.5, 95%CI: 0.4-15; P=0.318]. Response rate to venetoclax was similar for screening SUVmax <10 versus ≥10 (65% vs. 62%) (n=127 enrolled), though median progression-free survival was longer at <10 months (24.7 vs. 15.4 months; P=0.0335). Six patients developed Richter’s transformation on venetoclax, of whom two had screening biopsy demonstrating CLL (others did not have a biopsy) and five had screening SUVmax <10. We have defined the test characteristics for PET-CT to distinguish progression of CLL as compared to Richter’s transformation when biopsied in patients treated with B-cell receptor signaling pathway inhibitors. Overall diminished sensitivity and specificity as compared to prior reports of patients treated with chemotherapy/chemoimmunotherapy suggest it has diminished ability to discriminate these two diagnoses using a SUVmax ≥10 cutoff. This cutoff did not identify venetoclax-treated patients with an inferior response but may be predictive of inferior progression-free survival. (Registered at clinicaltrials.gov identifier: 02141282)
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Affiliation(s)
- Anthony R Mato
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Steven E Coutre
- Stanford Cancer Center, Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | | | | | - John C Byrd
- The Ohio State University, Columbus, OH, USA
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14
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Van Roosbroeck K, Bayraktar R, Calin S, Bloehdorn J, Dragomir MP, Okubo K, Bertilaccio MTS, Zupo S, You MJ, Gaidano G, Rossi D, Chen SS, Chiorazzi N, Thompson PA, Ferrajoli A, Bertoni F, Stilgenbauer S, Keating MJ, Calin GA. The involvement of microRNA in the pathogenesis of Richter syndrome. Haematologica 2018; 104:1004-1015. [PMID: 30409799 PMCID: PMC6518906 DOI: 10.3324/haematol.2018.203828] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022] Open
Abstract
Richter syndrome is the name given to the transformation of the most frequent type of leukemia, chronic lymphocytic leukemia, into an aggressive lymphoma. Patients with Richter syndrome have limited response to therapies and dismal survival. The underlying mechanisms of transformation are insufficiently understood and there is a major lack of knowledge regarding the roles of microRNA that have already proven to be causative for most cases of chronic lymphocytic leukemia. Here, by using four types of genomic platforms and independent sets of patients from three institutions, we identified microRNA involved in the transformation of chronic lymphocytic leukemia to Richter syndrome. The expression signature is composed of miR-21, miR-150, miR-146b and miR-181b, with confirmed targets significantly enriched in pathways involved in cancer, immunity and inflammation. In addition, we demonstrated that genomic alterations may account for microRNA deregulation in a subset of cases of Richter syndrome. Furthermore, network analysis showed that Richter transformation leads to a complete rearrangement, resulting in a highly connected microRNA network. Functionally, ectopic overexpression of miR-21 increased proliferation of malignant B cells in multiple assays, while miR-150 and miR-26a were downregulated in a chronic lymphocytic leukemia xenogeneic mouse transplantation model. Together, our results suggest that Richter transformation is associated with significant expression and genomic loci alterations of microRNA involved in both malignancy and immunity.
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Affiliation(s)
- Katrien Van Roosbroeck
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Present address - Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Recep Bayraktar
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steliana Calin
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mihnea Paul Dragomir
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keishi Okubo
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Simonetta Zupo
- Molecular Diagnostic Laboratory, Pathology Department, IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - M James You
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Davide Rossi
- Università della Svizzera italiana, Institute of Oncology Research, Bellinzona, Switzerland
| | - Shih-Shih Chen
- The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Nicholas Chiorazzi
- The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Philip A Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Bertoni
- Università della Svizzera italiana, Institute of Oncology Research, Bellinzona, Switzerland
| | | | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George A Calin
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA .,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Center for RNA Interference and Non-Coding RNAs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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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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16
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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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17
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Eyre TA, Schuh A. An update for Richter syndrome - new directions and developments. Br J Haematol 2017; 178:508-520. [DOI: 10.1111/bjh.14700] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Toby A. Eyre
- Department of Haematology; Cancer and Haematology Centre; Oxford University Hospitals NHS Trust; Oxford UK
- Early Phase Clinical Trial Unit; Oxford University Hospitals NHS Foundation Trust; Churchill Hospital; Oxford UK
| | - Anna Schuh
- Department of Haematology; Cancer and Haematology Centre; Oxford University Hospitals NHS Trust; Oxford UK
- Early Phase Clinical Trial Unit; Oxford University Hospitals NHS Foundation Trust; Churchill Hospital; Oxford UK
- NIHR BRC Oxford Molecular Diagnostic Centre; Oxford University Hospitals NHS Foundation Trust; Oxford UK
- Department of Oncology; University of Oxford; Oxford UK
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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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Eyre TA, Clifford R, Bloor A, Boyle L, Roberts C, Cabes M, Collins GP, Devereux S, Follows G, Fox CP, Gribben J, Hillmen P, Hatton CS, Littlewood TJ, McCarthy H, Murray J, Pettitt AR, Soilleux E, Stamatopoulos B, Love SB, Wotherspoon A, Schuh A. NCRI phase II study of CHOP in combination with ofatumumab in induction and maintenance in newly diagnosed Richter syndrome. Br J Haematol 2016; 175:43-54. [PMID: 27378086 DOI: 10.1111/bjh.14177] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/15/2016] [Indexed: 01/21/2023]
Abstract
Richter syndrome (RS) is associated with chemotherapy resistance and a poor historical median overall survival (OS) of 8-10 months. We conducted a phase II trial of standard CHOP-21 (cyclophosphamide, doxorubicin, vincristine, prednisolone every 21 d) with ofatumumab induction (Cycle 1: 300 mg day 1, 1000 mg day 8, 1000 mg day 15; Cycles 2-6: 1000 mg day 1) (CHOP-O) followed by 12 months ofatumumab maintenance (1000 mg given 8-weekly for up to six cycles). Forty-three patients were recruited of whom 37 were evaluable. Seventy-three per cent were aged >60 years. Over half of the patients received a fludarabine and cyclophosphamide-based regimen as prior CLL treatment. The overall response rate was 46% (complete response 27%, partial response 19%) at six cycles. The median progression-free survival was 6·2 months (95% confidence interval [CI] 4·9-14·0 months) and median OS was 11·4 months (95% CI 6·4-25·6 months). Treatment-naïve and TP53-intact patients had improved outcomes. Fifteen episodes of neutropenic fever and 46 non-neutropenic infections were observed. There were no treatment-related deaths. Seven patients received platinum-containing salvage at progression, with only one patient obtaining an adequate response to proceed to allogeneic transplantation. CHOP-O with ofatumumab maintenance provides minimal benefit beyond CHOP plus rutuximab. Standard immunochemotherapy for RS remains wholly inadequate for unselected RS. Multinational trials incorporating novel agents are urgently needed.
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Affiliation(s)
- Toby A Eyre
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Ruth Clifford
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Adrian Bloor
- Department of Haematology, The Christie Hospital NHS Trust, Wimslow Road, Manchester, UK
| | - Lucy Boyle
- OCTO - Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Oxford, UK
| | - Corran Roberts
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Maite Cabes
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Graham P Collins
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | | | - George Follows
- Department of Haematology, Addenbrooke's Hospital NHS Trust, Cambridge, UK
| | - Christopher P Fox
- Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - John Gribben
- Institute of Cancer, Barts & the London School of Medicine & Dentistry, London, UK
| | - Peter Hillmen
- St James's Institute of Oncology; Dena Cohen, University of Leeds, Leeds, UK
| | - Chris S Hatton
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Tim J Littlewood
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Helen McCarthy
- Department of Haematology, Royal Bournemouth Hospital, Bournemouth, UK
| | - Jim Murray
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Andrew R Pettitt
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, Merseyside, UK
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Elizabeth Soilleux
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Basile Stamatopoulos
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Sharon B Love
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Wotherspoon
- Laboratory of Clinical Cell Therapy, Jules Bordet Institute, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Anna Schuh
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK.
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.
- Department of Histopathology, The Royal Marsden Hospital, London, UK.
- Department of Oncology, University of Oxford, Oxford, UK.
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20
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Abstract
Richter syndrome (RS) is the development of an aggressive lymphoma in patients with a previous or concomitant diagnosis of chronic lymphocytic leukemia (CLL). The incidence rate RS is ~0.5% per year of observation. Two biomarkers (NOTCH1 mutations and subset 8 configuration of the B-cell receptor) may help identifying CLL patients at risk of RS to be considered for close monitoring and a careful biopsy policy. In the presence of clinical features suspicious of RS, diagnosis of transformation and choice of the site of biopsy may take advantage of fluorine 18 fluorodeoxyglucose ((18)FDG) positron emission tomography (PET)/computed tomography (CT). Molecular lesions of regulators of tumor suppression (TP53), cell cycle (CDKN2A), and cell proliferation (NOTCH1, MYC) overall account for ~90% of RS and may be responsible for the aggressive clinical phenotype observed in this disease because of the combined effect of chemoresistance and rapid disease kinetics. The prognosis of RS is generally highly unfavorable. However, the pattern of survival is not homogeneous and the most important prognostic factor is the clonal relationship between the CLL and the aggressive lymphoma clones. Rituximab-containing polychemotherapy represents the backbone for induction treatment in RS. Younger patients who respond to induction therapy should be offered stem cell transplant (SCT) to prolong survival.
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Affiliation(s)
- Davide Rossi
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy.
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, Novara, Italy
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21
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A Rare Cause of Cavitary Lesion in the Lung: Richter's Transformation. Case Rep Pulmonol 2015; 2015:945268. [PMID: 25810941 PMCID: PMC4354960 DOI: 10.1155/2015/945268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 02/17/2015] [Accepted: 02/21/2015] [Indexed: 11/26/2022] Open
Abstract
Richter's transformation (RT) refers to the development of aggressive lymphoma during the course of CLL. Clinically, patients with RT present with an aggressive disease course with rapidly enlarging lymph nodes, hepatosplenomegaly, and elevated serum lactate dehydrogenase levels. But rarely it presents with extra nodal organ involvement at the beginning. Common sites of extra nodal involvement are the gastrointestinal tract, eye, central nervous system, lung, and kidney. We are reporting this case that was presented with RT in the lung involvement diagnosed while researching cavitary lesion etiology.
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22
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Eyre TA, Clifford R, Roberts C, Boyle L, Francis A, Schuh A, Dutton SJ. Single arm NCRI phase II study of CHOP in combination with Ofatumumab in induction and maintenance for patients with newly diagnosed Richter's syndrome. BMC Cancer 2015; 15:52. [PMID: 25775024 PMCID: PMC4329650 DOI: 10.1186/s12885-015-1048-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 01/28/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Transformation of B-cell chronic lymphocytic leukaemia (B-CLL) to diffuse large B cell lymphoma (DLBCL) (Richter's syndrome (RS)) is a rare (2-15% of patients) but catastrophic complication of B-CLL. Dose-intense chemotherapy regimens investigated in small single institution trials, but with the exception of bone marrow transplantation for a minority of patients, little has improved the median overall survival of patients with RS beyond eight months. Patients are often elderly, immunosuppressed, possess co-morbidities and have a deteriorating performance status. TP53 disruption is a common molecular abnormality noted in RS and contributes to the tumour's chemotherapy resistance. Ofatumumab is a fully human anti-CD20 monoclonal IgG1κ antibody that targets a unique epitope on B lymphocytes. It has displayed increased binding affinity and a longer dissociation time when compared to rituximab resulting in improved complement dependent cellular cytotoxicity (CDCC); a mechanism with the potential to overcome apoptosis-resistance in TP53 disruption. Given the prevalence of TP53 disruption in RS, Ofatumumab was considered a relatively non-toxic agent with a sound rationale to test in a prospective multicentre trial as an adjunct to CHOP induction and subsequent ofatumumab maintenance therapy in responding patients. METHODS/DESIGN The CHOP-OR study is a prospective phase II study to evaluate the safety, feasibility and activity of a CHOP chemotherapy in combination with ofatumumab in induction and subsequent maintenance for patients with newly diagnosed RS. The primary objective will be the overall response rate (ORR) in patients with RS after six cycles of CHOP-O. The secondary objectives include feasibility of recruitment, progression free survival (PFS), overall survival (OS) and toxicity. The study will be accompanied by exploratory analysis of the genomic landscape of RS in newly diagnosed patients. DISCUSSION The CHOP-OR trial evaluates the safety, feasibility and activity of CHOP plus Ofatumumab induction and Ofatumumab maintenance in new RS patients. The study is currently recruiting and has met the interim analysis criteria, with more than 7 of the first 25 participants achieving a CR or PR after six cycles of CHOP-O. The study has the potential to identify predictive biomarkers for this treatment modality. TRIAL REGISTRATION NCT01171378.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/drug effects
- Cyclophosphamide/therapeutic use
- Doxorubicin/therapeutic use
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Prednisone/therapeutic use
- Prospective Studies
- Single-Blind Method
- Tumor Suppressor Protein p53/metabolism
- Vincristine/therapeutic use
- Young Adult
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Affiliation(s)
- Toby A Eyre
- Department of Haematology & The Early Phase Clinical Trial Unit, Oxford University Hospitals NHS Trust, Churchill Hospital, Oxford, OX3 7EJ UK
| | - Ruth Clifford
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Corran Roberts
- Centre for Statistics in Medicine (CSM), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, The Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Lucy Boyle
- CHOP-OR Trial Office, OCTO - Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Anne Francis
- CHOP-OR Trial Office, OCTO - Oncology Clinical Trials Office, Department of Oncology, University of Oxford, Old Road Campus Research Building, Roosevelt Drive, Oxford, OX3 7DQ UK
| | - Anna Schuh
- NIHR BRC Oxford Molecular Diagnostic Centre, Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit & Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, The Botnar Research Centre, University of Oxford, Windmill Road Oxford, OX3 7LD UK
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23
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24
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Durot E, Michallet AS, Leprêtre S, Le QH, Leblond V, Delmer A. Platinum and high-dose cytarabine-based regimens are efficient in ultra high/high-risk chronic lymphocytic leukemia and Richter's syndrome: results of a French retrospective multicenter study. Eur J Haematol 2015; 95:160-7. [DOI: 10.1111/ejh.12474] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 01/04/2023]
Affiliation(s)
- Eric Durot
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
| | | | - Stéphane Leprêtre
- Département d'Hématologie, Unicancer; Centre Henri Becquerel; Rouen France
| | - Quoc-Hung Le
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
| | - Véronique Leblond
- AP-HP; Service d'Hématologie Clinique; Hôpital Pitié-Salpêtrière; Paris France
- UPMC Université Paris 06 GRC11-GRECHY; Paris France
| | - Alain Delmer
- Service d'Hématologie Clinique; Centre Hospitalier Universitaire; Hôpital Robert Debré; Reims France
- UFR Médecine; Université Reims Champagne-Ardenne; Reims France
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25
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Parikh SA, Kay NE, Shanafelt TD. How we treat Richter syndrome. Blood 2014; 123:1647-57. [PMID: 24421328 PMCID: PMC3954047 DOI: 10.1182/blood-2013-11-516229] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/07/2014] [Indexed: 01/13/2023] Open
Abstract
Richter syndrome (RS) is defined as the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). RS occurs in approximately 2% to 10% of CLL patients during the course of their disease, with a transformation rate of 0.5% to 1% per year. A combination of germline genetic characteristics, clinical features (eg, advanced Rai stage), biologic (ζ-associated protein-70(+), CD38(+), CD49d(+)) and somatic genetic (del17p13.1 or del11q23.1) characteristics of CLL B cells, and certain CLL therapies are associated with higher risk of RS. Recent studies have also identified the crucial role of CDKN2A loss, TP53 disruption, C-MYC activation, and NOTCH1 mutations in the transformation from CLL to RS. An excisional lymph node biopsy is considered the gold standard for diagnosis of RS; a (18)F-fluorodeoxyglucose positron emission tomography scan can help inform the optimal site for biopsy. Approximately 80% of DLBCL cases in patients with CLL are clonally related to the underlying CLL, and the median survival for these patients is approximately 1 year. In contrast, the remaining 20% of patients have a clonally unrelated DLBCL and have a prognosis similar to that of de novo DLBCL. For patients with clonally related DLBCL, induction therapy with either an anthracycline- or platinum-based regimen is the standard approach. Postremission stem cell transplantation should be considered for appropriate patients. This article summarizes our approach to the clinical management of CLL patients who develop RS.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/pathology
- Combined Modality Therapy
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Middle Aged
- Prognosis
- Stem Cell Transplantation
- Transplantation, Autologous
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Affiliation(s)
- Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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26
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Correlation between FDG/PET, histology, characteristics, and survival in 332 patients with chronic lymphoid leukemia. Blood 2014; 123:2783-90. [PMID: 24615780 DOI: 10.1182/blood-2013-11-536169] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Richter syndrome (RS) is associated with poor outcome. The prognosis of patients with histologically aggressive chronic lymphocytic leukemia (CLL), or HAC, has not been studied. We aimed to correlate 2-deoxy-2-[(18)F]fluoroglucose/positron emission tomography (FDG/PET) data, histological diagnosis, clinical characteristics, and survival in patients with CLL. A total of 332 patients with CLL were histologically classified as: 95 RS, 117 HAC, and 120 histologically indolent CLL (HIC). HAC and RS patients had higher maximum standardized uptake value (SUVmax), more frequent constitutional symptoms, poorer performance status (PS), lower hemoglobin and platelets, and higher lactate dehydrogenase and β-2-microglobulin. An SUVmax ≥10 strongly correlated with mortality (overall survival [OS], 56.7 vs 6.9 months in patients with SUVmax <10 vs ≥10). Survival of patients with RS and HAC was similar among patients with SUVmax <10 or ≥10. SUVmax ≥10, PS ≥2, bulky disease, and age ≥65 were independently associated with shorter OS. In patients undergoing both fine-needle aspiration and biopsy, the former proved diagnostically inadequate in 23%, 29%, and 53% of HIC, HAC, and RS, respectively. FDG/PET is a useful diagnostic tool in patients with CLL and suspected transformation. Patients with HAC show different characteristics and worse prognosis compared with those with HIC. Patients with different CLL phases, but similar SUVmax have similar outcome. Tissue biopsy should be preferred for diagnosing RS.
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Strati P, Ferrajoli A, Lerner S, O'Brien S, Wierda W, Keating MJ, Faderl S. Fludarabine, cyclophosphamide and rituximab plus granulocyte macrophage colony-stimulating factor as frontline treatment for patients with chronic lymphocytic leukemia. Leuk Lymphoma 2013; 55:828-33. [PMID: 23808813 DOI: 10.3109/10428194.2013.819574] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Fludarabine, cyclophosphamide and rituximab (FCR), the standard of care for the frontline treatment of patients with chronic lymphocytic leukemia (CLL), is associated with a high rate of neutropenia and infectious complications. Granulocyte macrophage colony-stimulating factor (GM-CSF) reduces myelosuppression and can potentiate rituximab activity. We conducted a clinical trial combining GM-CSF with FCR for frontline treatment of 60 patients with CLL. Eighty-six percent completed all six courses and 18% discontinued GM-CSF for toxicity: grade 3-4 neutropenia was observed in 30% of cycles, and severe infections in 16% of cases. The overall response rate was 100%. Both median event-free survival (EFS) and overall survival (OS) have not been reached. Longer EFS was associated with favorable cytogenetics. GM-CSF led to a lower frequency of infectious complications than in the historical FCR group, albeit similar EFS and OS.
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Affiliation(s)
- Paolo Strati
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center , Houston, TX , USA
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Elazzazy S, El-Geed HA, Al Yafei S. Severe hypophosphatemia induced after first cycle of the ESHAP protocol for Hodgkin's lymphoma: a case report. Int Med Case Rep J 2013; 6:1-5. [PMID: 23750103 PMCID: PMC3666155 DOI: 10.2147/imcrj.s37286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The effect of the ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin) salvage protocol on serum electrolytes has been previously reported by individual observational studies. The most commonly described electrolyte affected by the ESHAP protocol is magnesium. In addition, hypophosphatemia has been studied and reported as a complication of cisplatin therapy, although it is usually asymptomatic. This is a case report of a 51-year-old woman with relapsed Hodgkin's lymphoma who developed severe hypophosphatemia following administration of the first cycle of the ESHAP protocol. The patient started to develop gradually decreasing phosphate levels 2 weeks after receiving chemotherapy, which needed to be corrected by phosphate supplementation. This case report raises concern regarding hypophosphatemia as a possible side effect of the ESHAP protocol and points to a need for close monitoring, taking into consideration vitamin D levels, urinary phosphate excretion, parathyroid hormone levels, and arterial blood gas analysis to rule out other contributing factors. Health care providers should be made aware of this possible toxicity. Critical monitoring of phosphate levels and considering supplementation is warranted with the ESHAP protocol, especially when it is used in combination with granulocyte colony-stimulating factor and diuretics, to prevent such possible hypophosphatemia. Further investigations may be required to confirm and evaluate the significance of this type of toxicity.
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Affiliation(s)
- Shereen Elazzazy
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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Abstract
Transformation of chronic lymphocytic leukemia (CLL) to aggressive lymphoma is known as Richter syndrome (RS). In the CLL population considered as a whole, the prevalence of RS development ranges from 2 to 7 %. The most common pathologic phenotype at the time of RS transformation is diffuse large B-cell lymphoma (DLBCL), while, in a small fraction of cases, the transformed phase shows pathologic features mimicking Hodgkin lymphoma. TP53 disruption and MYC activation cooperate as dual hits in driving DLBCL transformation. Two biomarkers (NOTCH1 mutations and usage of the immunoglobulin VH CDR3 subset 8) may help in identifying CLL patients at risk of DLBCL transformation to be considered for close monitoring and a careful biopsy policy. In the presence of clinical features suspicious of RS, diagnosis of transformation and choice of the site of biopsy may take advantage of (18)FDG PET/CT. The prognosis of RS transformation is generally highly unfavorable. However, the pattern of survival is not homogeneous and may be predicted on clinical and biological grounds. RS that are clonally unrelated to the paired CLL phase are biologically and clinically different from clonally related cases, and should be considered, and probably managed, as a de novo DLBCL arising in the context of CLL. Rituximab-containing polychemotherapy represents the backbone for induction treatment in patients with clonally related DLBCL transformation. Younger patients who respond to induction therapy should be offered stem cell transplant to prolong survival.
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Clifford R, Schuh A. State-of-the-Art Management of Patients Suffering from Chronic Lymphocytic Leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2012; 6:165-78. [PMID: 22474408 PMCID: PMC3315290 DOI: 10.4137/cmo.s6201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of chronic lymphocytic leukemia (CLL) has evolved dramatically in the last decade. For the first time, clinical intervention has been shown to alter the natural history of the disease. Considerable efforts are focussing on better patient selection and response prediction, and it is expected that the publication of the first 200 CLL genomes will spark new insights into risk stratification of CLL patients. Besides, many new agents are being evaluated on their own and in combination therapy in early and late Phase clinical studies. Here, we provide a general clinical introduction into CLL including diagnosis and prognostic markers followed by a summary of the current state-of-the-art treatment. We point to areas of continued clinical research in particular for patients with co-morbidities and highlight the challenges in managing refractory disease.
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Affiliation(s)
- Ruth Clifford
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Churchill Site, Oxford, OX3 7JL, United Kingdom
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Fan L, Wang L, Zhang R, Fang C, Zhu DX, Wang YH, Zou ZJ, Li JY, Xu W. Richter transformation in 16 of 149 Chinese patients with chronic lymphocytic leukemia. Leuk Lymphoma 2012; 53:1749-56. [PMID: 22329349 DOI: 10.3109/10428194.2012.664845] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
No confirmed risk factors are known to predict Richter syndrome (RS), and the value of clinical prognosticators conventionally applied to chronic lymphocytic leukemia (CLL) is not firmly established in this setting. The objective of this study was to present evidence for RS in Chinese patients with CLL and risk factors for CLL transformation to Richter syndrome. With a median follow-up of 43 months from CLL diagnosis in 149 Chinese patients, 16 (10.7%) patients progressed to diffuse large B-cell lymphoma (DLBCL). According to correlation analysis, a high level of lactate dehydrogenase (LDH) and CD38 positivity were found to be independent predictors of transformation to RS. Survival analysis showed that presence of RS, advanced Binet stage, high level of LDH, high level of β(2)-microglobulin, high concentration of thymidine kinase (TK), ZAP-70 and CD38 expression, unmutated immunoglobulin heavy chain variable (IGHV) gene status and del(17p13) were adverse factors in determining overall survival (OS). Only del(17p13) was strongly associated with survival by multivariate Cox regression analysis. Median OS after transformation was 16 months (95% confidence interval, 5.6-26.4 months). The results support that RS is associated with a poor outcome, and a policy of close monitoring and careful biopsy is needed in patients carrying transformation risk factors.
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Affiliation(s)
- Lei Fan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
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Tedeschi A, Vismara E, Ricci F, Morra E, Montillo M. The spectrum of use of rituximab in chronic lymphocytic leukemia. Onco Targets Ther 2010; 3:227-46. [PMID: 21289858 PMCID: PMC3024887 DOI: 10.2147/ott.s8151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The monoclonal chimeric anti-CD20 antibody, rituximab, has considerably improved therapeutic outcome in B-cell chronic lymphocytic leukemia. Rituximab has limited clinical activity when used as a single agent. The combination of the monoclonal antibody with fludarabine-based regimens clearly demonstrated, in Phase II and randomized trials, an increase in clinical efficacy in previously untreated and pretreated patients. Furthermore the addition of rituximab enabled the eradication of minimal residual disease, which is correlated with the prognosis in a high proportion of patients. Although the combination of rituximab with fludarabine-based regimens increased myelosuppression and immunosuppression, incidence of infections did not increase. The benefit of adding rituximab to other purine analogs or other chemotherapeutic combination regimens has also been explored. Moreover there could be a role for achieving better quality of responses with the combination of different monoclonal antibodies, considering that they target different antigens and exert different mechanism of action. Although the role of rituximab as maintenance therapy in low grade non-Hodgkin's lymphomas has been determined, the benefit and optimal schedule in chronic lymphocytic leukemia are still under investigation. This review brings together knowledge of the pharmacokinetics, mechanism of action and clinical use of rituximab in chronic lymphocytic leukemia.
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Affiliation(s)
| | - Eleonora Vismara
- Department of Hematology, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Francesca Ricci
- Department of Hematology, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Enrica Morra
- Department of Hematology, Niguarda Ca’ Granda Hospital, Milano, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Ca’ Granda Hospital, Milano, Italy
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Abstract
Hypophosphatemia (serum phosphorus concentration <2.5 mg/dl, 0.8 mmol/l), although rare in the general population, is commonly observed in hospitalized patients and may be associated with drug therapy. In fact, hypophosphatemia frequently develops in the course of treatment with drugs used in every-day clinical practice including diuretics and bisphosphonates. Proper diagnostic approach of patients with low serum phosphorus concentrations should involve a detailed medical history with special attention to the recent use of medications. The clinical manifestations of drug-induced hypophosphatemia are usually mild but might also be severe and potentially life-threatening. This review aims at a thorough understanding of the underlying pathophysiological mechanisms and risk factors of drug therapy-related hypophosphatemia thus allowing prevention and effective intervention strategies.
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Affiliation(s)
- G Liamis
- Department of Internal Medicine, School of Medicine, University of Ioannina, 45110 Ioannina, Greece
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Rasool J, Jeelani S, Jeelani S, Khan A, lone MS. Chest Wall Swelling, A Rare Presentation of Richter's Transformation. Indian J Hematol Blood Transfus 2010; 26:70-2. [PMID: 21629641 PMCID: PMC3002062 DOI: 10.1007/s12288-010-0024-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 07/26/2010] [Indexed: 12/01/2022] Open
Abstract
A large cell lymphoma develops in approximately 1-10% of chronic lymphocytic leukemia (CLL). This is known as Richter's syndrome. Chest wall swelling is a very unusual presentation of this syndrome. Here we report another such case of chest wall swelling, a very rare presentation of Richter's syndrome.
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Affiliation(s)
- Javid Rasool
- Clinical Hematology, SKIMS, Soura, Srinagar, Kashmir 190011 India
| | - Samoon Jeelani
- Clinical Hematology, SKIMS, Soura, Srinagar, Kashmir 190011 India
| | - Sajad Jeelani
- Clinical Hematology, SKIMS, Soura, Srinagar, Kashmir 190011 India
| | - Afaq Khan
- Clinical Hematology, SKIMS, Soura, Srinagar, Kashmir 190011 India
| | - Mohd Suhail lone
- Clinical Hematology, SKIMS, Soura, Srinagar, Kashmir 190011 India
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Rossi D, Gaidano G. Richter syndrome: molecular insights and clinical perspectives. Hematol Oncol 2009; 27:1-10. [PMID: 19206112 DOI: 10.1002/hon.880] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Richter syndrome (RS) represents the clinico-pathologic transformation of chronic lymphocytic leukaemia (CLL) to an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). The clinical definition of RS is heterogeneous, and encompasses at least two biologically different conditions: (i) CLL transformation to a clonally related DLBCL, that accounts for the majority of cases; (ii) development of a DLBCL unrelated to the CLL clone. In clonally related RS, the pathogenetic link between the CLL and the DLBCL phases is substantiated by the acquisition of novel molecular lesions at the time of clinico-pathologic transformation. RS is not a rare event in the natural history of CLL, since the cumulative incidence of RS at 10 years exceeds 10%. Prompt recognition of RS is known to be clinically useful, and may be favoured by close monitoring of CLL patients harbouring clinical and/or biological risk factors of RS development. Conventional risk factors that are independent predictors of RS development at the time of CLL diagnosis include: (i) expression of CD38; (ii) absence of del13q14 and (iii) lymph node size > or =3 cm. Other risk factors of RS development include CD38 genotype and usage of specific immunoglobulin variable genes. The molecular pathogenesis of RS has been elucidated to a certain extent. Acquisition of TP53 mutations and/or 17p13 deletion is a frequent molecular event in RS, as it is in other types of transformation from indolent to aggressive B-cell malignancies. Additional molecular alterations are being revealed by genome wide studies. Once that transformation has occurred, RS prognosis may be predicted by the RS score, based on performance status, LDH, platelet count, tumour size and number of prior therapies. Depending on patient's age and RS score, the therapeutic options for RS may range from conventional immunochemotherapy to allogeneic bone marrow transplantation.
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Affiliation(s)
- Davide Rossi
- Division of Hematology, Department of Clinical and Experimental Medicine and BRMA, Amedeo Avogadro University of Eastern Piedmont and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy.
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Primary cutaneous Richter syndrome: Prognostic implications and review of the literature. J Am Acad Dermatol 2009; 60:157-61. [DOI: 10.1016/j.jaad.2008.07.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2008] [Revised: 07/08/2008] [Accepted: 07/17/2008] [Indexed: 11/19/2022]
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Tsimberidou AM, Wierda WG, Plunkett W, Kurzrock R, O'Brien S, Wen S, Ferrajoli A, Ravandi-Kashani F, Garcia-Manero G, Estrov Z, Kipps TJ, Brown JR, Fiorentino A, Lerner S, Kantarjian HM, Keating MJ. Phase I-II Study of Oxaliplatin, Fludarabine, Cytarabine, and Rituximab Combination Therapy in Patients With Richter's Syndrome or Fludarabine-Refractory Chronic Lymphocytic Leukemia. J Clin Oncol 2008; 26:196-203. [DOI: 10.1200/jco.2007.11.8513] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Richter's syndrome (RS) and fludarabine-refractory chronic lymphocytic leukemia (CLL) are associated with poor clinical outcomes. We conducted a phase I-II trial of oxaliplatin, fludarabine, cytarabine, and rituximab (OFAR) in these diseases. Patients and Methods The OFAR regimen consisted of increasing doses of oxaliplatin (17.5, 20, or 25 mg/m2/d) on days 1 to 4 (phase I), fludarabine 30 mg/m2 on days 2 to 3, cytarabine 1 g/m2 on days 2 to 3, rituximab 375 mg/m2 on day 3 of cycle 1 and day 1 of subsequent cycles, and pegfilgrastim 6 mg on day 6, every 4 weeks for a maximum of six courses. Dose-limiting toxicity (DLT) was defined as any nonhematologic, treatment-related toxicity ≥ grade 3. Results Fifty patients were treated (20 patients had RS, and 30 had CLL). The highest tolerated oxaliplatin dose was 25 mg/m2, which was the highest dose tested. DLT was not observed. Pharmacodynamic analyses demonstrated enhanced leukemia cell killing by oxaliplatin in the presence of fludarabine and cytarabine. The overall response rates were 50% in RS and 33% in fludarabine-refractory CLL. The overall response rate in 14 patients with age ≥ 70 years was 50%. Responses were achieved in seven (35%) of 20 patients with 17p deletion, two (29%) of seven patients with 11q deletion, all four patients with trisomy 12, and two (40%) of five patients with 13q deletion. The median response duration was 10 months. Toxicities were mainly hematologic; prolonged myelosuppression was not observed. Conclusion The OFAR regimen is highly active in RS and has activity in fludarabine-refractory patients with CLL. This regimen warrants further investigation in the treatment of these disorders.
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Affiliation(s)
- Apostolia M. Tsimberidou
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - William G. Wierda
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - William Plunkett
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Razelle Kurzrock
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Susan O'Brien
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Sijin Wen
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Alessandra Ferrajoli
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Farhad Ravandi-Kashani
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Guillermo Garcia-Manero
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Zeev Estrov
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Thomas J. Kipps
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer R. Brown
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Albert Fiorentino
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Susan Lerner
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Hagop M. Kantarjian
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
| | - Michael J. Keating
- From the Departments of Leukemia, Experimental Therapeutics, Phase I Program, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX; University of California San Diego Moore's Cancer Center, San Diego, CA; and Dana-Farber Cancer Institute, Boston, MA
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Sampath D, Plunkett W. The role of DNA repair in chronic lymphocytic leukemia pathogenesis and chemotherapy resistance. Curr Oncol Rep 2007; 9:361-7. [PMID: 17706164 DOI: 10.1007/s11912-007-0048-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Front-line therapy for chronic lymphocytic leukemia (CLL) with alkylating agents is associated with low rates of complete remission and no improvement in overall survival. The ability of CLL cells to efficiently repair alkylator-induced damage to DNA might explain this lack of response. Novel strategies that inhibit DNA repair, such as combinations of alkylating agents, purine nucleoside analogues, and immunotherapy, have produced durable clinical and molecular remission in both untreated and relapsed CLL. This review evaluates the contribution of DNA repair processes in the development of resistance to chemotherapy and the impact of therapies that exploit the DNA repair capacity of CLL cells to therapeutic advantage.
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Affiliation(s)
- Deepa Sampath
- Department of Experimental Therapeutics, Unit 71, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Tsimberidou AM, Keating MJ, Wierda WG. Richter’s transformation in chronic lymphocytic leukemia. Curr Hematol Malig Rep 2007; 2:265-71. [DOI: 10.1007/s11899-007-0036-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Swords R, Bruzzi J, Giles F. Recent advances in the diagnosis and therapy of richter’s syndrome. Med Oncol 2007; 24:17-32. [PMID: 17673808 DOI: 10.1007/bf02685899] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 11/30/1999] [Accepted: 10/26/2006] [Indexed: 11/25/2022]
Abstract
Richter's syndrome (RS) denotes the development of aggressive lymphoma that arises in patients with chronic lymphocytic leukemia (CLL). Presenting features typically include a rapid clinical deterioration with fever in the absence of infection, progressive lymph node enlargement, and an elevation in serum LDH. Diagnostic biopsy of affected sites usually reveals large cell lymphomas; however, Hodgkin variant cases have been described. Richter's transformation occurs in approx 5% of CLL patients and may be associated with infection with Epstein-Barr virus (EBV). Chromosome 11 and 14 abnormalities have also been described as well as tumor suppressor gene defects involving p53, p21, and p27. Treatment options for these patients are limited and include combination chemotherapy with or without the addition of monoclonal antibodies and stem cell transplantation. Response to therapy is variable and generally short-lived. Median survival is usually in the order of 5-8 mo. More effective management for RS is needed as well as prognostic models that will identify CLL patients at risk of transformation. This review will address the current status of RS and deal with the pathophysiology, diagnostic approach, and treatment of this challenging disease.
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Affiliation(s)
- Ronan Swords
- Department of Haematology, University College Hospital Galway, Galway, Ireland
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Abstract
Richter's syndrome, that is, transformation of chronic lymphocytic leukemia to a large cell or immunoblastic lymphoma, occurs in up to 10% of patients with chronic lymphocytic leukemia. The onset of Richter's syndrome is characterized by worsening systemic symptoms, rapid tumor growth, and/or extranodal involvement. Median survival with conventional chemotherapy is less than 6 months. Therapy with more recent therapeutic regimens, such as hyperCVXD (fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone), augmented hyperCVXD, and yttrium-90 ibritumomab tiuxetan, has not produced major improvements in response rates or overall survival. Improvement in the outcome of patients with Richter's syndrome may be aided by a more comprehensive understanding of the pathogenesis of Richter's syndrome; therapy could then be targeted against specific abnormalities. Current data indicate that the transformation of chronic lymphocytic leukemia to a large-cell or immunoblastic lymphoma is associated with abnormalities in cell cycle regulation (e.g., loss of the cell cycle inhibitors p16(INK4a) and p27(KIP1) ) and DNA repair (e.g., mutations and/or deletions of the p53, ATM, and p14(ARF) genes and epigenetic silencing of the MLH1 gene). However, the critical event leading to transformation is unclear. Given the poor prognosis of patients with Richter's syndrome, every effort should be made to enroll these patients into clinical trials evaluating novel agents with the appropriate correlative studies.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Cycle
- Cell Transformation, Neoplastic
- Humans
- Immunoconjugates/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/physiopathology
- Lymphoma, Large-Cell, Immunoblastic/drug therapy
- Lymphoma, Large-Cell, Immunoblastic/genetics
- Lymphoma, Large-Cell, Immunoblastic/physiopathology
- Prognosis
- Risk Factors
- Stem Cell Transplantation
- Survival
- Syndrome
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Affiliation(s)
- Karen W L Yee
- Section of Developmental Therapeutics, Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA
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Abstract
Richter's transformation denotes the development of high-grade non-Hodgkin lymphoma, prolymphocytic leukemia, Hodgkin disease, or acute leukemia in patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma. A search of published articles in Medline (PubMed) and abstracts from professional meetings was performed. An electronic database search of patients with CLL at The University of Texas M. D. Anderson Cancer Center (Houston, TX) determined the incidence of Richter syndrome (RS) in patients with CLL between 1992 and 2002. RS occurs in approximately 5% of patients with CLL. The large cells of RS may arise through transformation of the original CLL clone or represent a new neoplasm. RS may be triggered by viral infections, such as Epstein-Barr virus. Trisomy 12 and chromosome 11 abnormalities are more frequent in patients with RS than in the overall population of patients with CLL. Multiple genetic defects, such as mutations of the p53 tumor suppressor gene, p16INK4A, and p21, loss of p27 expression, deletion of retinoblastoma, increased copy number of C-MYC, and decreased expression of the A-MYB gene, have been described. These abnormalities may cause CLL cells to proliferate and-by facilitating the acquisition of new genetic abnormalities-to transform into RS cells. Therapeutic strategies include intensive chemotherapy, monoclonal antibodies, and stem cell transplantation. The response rates range from 5% to 43% (complete response, 5-38%), and the median survival duration ranges from 5 months to 8 months. In conclusion, RS may be triggered by viral infections or by genetic defects. Current treatments are aggressive, but prognosis is poor. Novel curative treatment strategies are needed.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Combined Modality Therapy
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Non-Hodgkin/diagnosis
- Lymphoma, Non-Hodgkin/epidemiology
- Lymphoma, Non-Hodgkin/therapy
- Male
- Prognosis
- Risk Assessment
- Severity of Illness Index
- Stem Cell Transplantation/methods
- Survival Analysis
- Syndrome
- Treatment Outcome
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44
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Tsimberidou AM, Murray JL, O'Brien S, Wierda WG, Keating MJ. Yttrium-90 ibritumomab tiuxetan radioimmunotherapy in Richter syndrome. Cancer 2004; 100:2195-200. [PMID: 15139064 DOI: 10.1002/cncr.20252] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND (90)Y ibritumomab tiuxetan is a radioimmunotherapeutic construct that is reported to be an effective treatment for patients with lymphoma. The aim of the current analysis was to evaluate retrospectively the efficacy and safety of (90)Y ibritumomab tiuxetan in patients with Richter syndrome (RS). METHODS Patients with histologically proven CD20-positive RS and < 25% lymphoma and/or chronic lymphocytic leukemia in the bone marrow were treated. Patients received an imaging dose of (111)In-labeled ibritumomab tiuxetan of 1.6 mg (5.0 mCi of (111)In) intravenously. One week later, they received 0.3 or 0.4 mCi/kg of (90)Y ibritumomab tiuxetan. Rituximab, at a dose of 250 mg/m(2) intravenously, was given immediately before ibritumomab tiuxetan on Days 1 and 8. RESULTS Seven patients were treated. Their median age was 56 years (range, 44-70 years). The median time to transformation was 7.9 years (range, 0.7-28.4 years). The median number of previous therapies received was five (range, one to seven previous therapies). The median number of previous therapies received for RS was one (range, none to three previous therapies). Six patients were treated previously with hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and cytosine arabinoside. No patient responded to (90)Y ibritumomab tiuxetan therapy. All patients developed disease progression. The median time to disease progression was 41 days (range, 39-89 days). Side effects included hematologic toxicity. Grade 3-4 (according to the second version of the National Cancer Institute Common Toxicity Criteria) thrombocytopenia and neutropenia occurred in 5 patients (71%) and 2 patients (29%), respectively. There was one episode of septic shock in a patient with Grade 4 neutropenia. CONCLUSIONS (90)Y ibritumomab tiuxetan had no significant antitumor activity and hematologic toxicity was severe in these heavily pretreated patients with RS.
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MESH Headings
- Adult
- Aged
- Antibodies, Monoclonal/therapeutic use
- Antineoplastic Agents/therapeutic use
- Bone Marrow/pathology
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, B-Cell/immunology
- Lymphoma, B-Cell/therapy
- Male
- Middle Aged
- Radioimmunotherapy
- Retrospective Studies
- Syndrome
- Treatment Outcome
- Yttrium Radioisotopes/therapeutic use
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45
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Tsimberidou AM, Kantarjian HM, Cortes J, Thomas DA, Faderl S, Garcia-Manero G, Verstovsek S, Ferrajoli A, Wierda W, Alvarado Y, O'Brien SM, Albitar M, Keating MJ, Giles FJ. Fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone plus rituximab and granulocyte-macrophage-colony stimulating factor (GM-CSF) alternating with methotrexate and cytarabine plus rituximab and GM-CSF in patients with Richter syndrome or fludarabine-refractory chronic lymphocytic leukemia. Cancer 2003; 97:1711-20. [PMID: 12655528 DOI: 10.1002/cncr.11238] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Therapy for patients with Richter syndrome (RS) or fludarabine-refractory chronic lymphocytic leukemia (CLL) is unsatisfactory. A Phase II study was conducted to evaluate an alternating combination cytotoxic regimen given with rituximab and granulocyte-macrophage-colony stimulating factor (GM-CSF) in these patients. METHODS Fludarabine-refractory CLL was defined as failure to respond to most recent prior fludarabine-containing regimen. Patients received up to six cycles of fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone (hyper-CVXD) plus rituximab and GM-CSF alternating with methotrexate and cytarabine plus rituximab and GM-CSF. Response, toxicity, and survival data were compared with data from prior therapy with hyper-CVXD alone in this patient group. RESULTS Forty-nine patients with RS (n = 30 patients) or refractory CLL (n = 19 patients) were treated on study. Nine patients (18%) achieved a complete remission, and 11 patients achieved a partial remission (22%), for an overall objective response (OR) rate of 41%. With a median follow-up of 7.5 months and a maximum follow-up of 15.2 months, the 12-month failure free survival (FFS) rate was 27%, and the overall survival (OS) rate was 39%. Nine patients (18%) died during the first cycle of therapy, and two patients (4%) died during the second cycle. There were no significant differences between the rates of OR, OS, and FFS in the current study and those obtained with hyper-CVXD alone on a prior study. CONCLUSIONS The study regimen had activity and significant toxicity in patients with RS or fludarabine-refractory CLL. It was not clearly better compared with hyper-CVXD alone in this patient population.
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MESH Headings
- Adult
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cyclophosphamide/administration & dosage
- Daunorubicin/administration & dosage
- Dexamethasone/administration & dosage
- Drug Administration Schedule
- Drug Resistance, Neoplasm
- Female
- Granulocyte-Macrophage Colony-Stimulating Factor/administration & dosage
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Prognosis
- Rituximab
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
- Vincristine/administration & dosage
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Affiliation(s)
- Apostolia M Tsimberidou
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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