1
|
Subramanian J, Cavenagh J, Desai B, Jacobs I. Rituximab in the treatment of follicular lymphoma: the future of biosimilars in the evolving therapeutic landscape. Cancer Manag Res 2017; 9:131-140. [PMID: 28479860 PMCID: PMC5411111 DOI: 10.2147/cmar.s120589] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Follicular lymphoma (FL) is the second most common type of non-Hodgkin's lymphoma. FL is an incurable disease with treatment options ranging from a "watch-and-wait" approach to localized therapy with radiation or systemic therapy with rituximab in combination with chemotherapy regimens. This review summarizes the role of rituximab across the spectrum of FL treatment and the evolving therapeutic landscape with the emergence of novel agents currently in clinical development. Despite the prospect of new agents on the horizon, it is widely accepted that rituximab will remain as the cornerstone of therapy because of its established long-term efficacy. Many biologics, including rituximab, have lost exclusivity of composition-of-matter patent or will do so in the next few years, which is a concern for patients and physicians alike. Moreover, access to rituximab is challenging, particularly in countries with restricted resources. Together, these concerns have fueled the development of safe and effective biosimilars. The term "biosimilar" refers to a biologic product that is highly similar to an approved reference (or originator) product, notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences in purity, potency, or safety. Biosimilars are developed to treat the same condition(s) using the same treatment regimens as an approved reference biologic, and have the potential to increase access to more affordable treatment of FL. Herein, we also discuss the potential benefits of eagerly awaited rituximab biosimilars, which may mitigate the impact of the lack of access to rituximab.
Collapse
Affiliation(s)
| | - Jamie Cavenagh
- Department of Haematology, St. Bartholomew’s Hospital, London, UK
| | | | - Ira Jacobs
- Global Established Pharma, Pfizer Inc., New York, NY, USA
| |
Collapse
|
2
|
Dreyling M, Ghielmini M, Marcus R, Salles G, Vitolo U, Ladetto M. Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii76-82. [PMID: 25122695 DOI: 10.1093/annonc/mdu200] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- M Dreyling
- Department of Medicine III, University of Munich, Munich, Germany
| | - M Ghielmini
- Oncology Institute of Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland
| | - R Marcus
- Haematology, Kings College Hospital, London, UK
| | - G Salles
- Service D'Hématologie, Centre Hospitalier Lyon-Sud, Pierre-Benite, France
| | - U Vitolo
- Haematology II, Centro Universitario Ricerca Oncologica Ospedale Molinette, Turin
| | - M Ladetto
- Divisione di Ematologia, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | |
Collapse
|
3
|
Schwartzberg L, Hermann R, Flinn I, Flora D, Hsi ED, Hamid O, Shi P, Lin BK, Myrand SP, Nguyen TS, Dreyling M. Open-label, single-arm, phase II study of enzastaurin in patients with follicular lymphoma. Br J Haematol 2014; 166:91-7. [PMID: 24673609 DOI: 10.1111/bjh.12853] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 02/12/2014] [Indexed: 12/16/2022]
Abstract
This open-label, phase II study investigated whether enzastaurin, a protein kinase C-beta (PKCβ) inhibitor, had activity in patients with grade 1 or 2 follicular lymphoma (FL). Adults with grade 1 or 2 FL who had no more than one prior treatment received oral enzastaurin continuously for up to 3 years. Of the 66 patients who received enzastaurin, 53 were evaluable for response. Overall response rate (ORR, primary efficacy endpoint) was 26.4% (3.8% complete response). Median (95% confidence interval) progression-free survival, time to response, and duration of response were 18.1 (11.5-28.3), 4.9 (2.8-8.1), and 22.3 (8.8-not applicable) months, respectively. In patients with tumour tissue available for biomarker analysis, ORRs in low versus high PKCβ2 expression groups were 41.7% and 8.3%, respectively (P = 0.041). The most common, mainly low-grade drug-related adverse events were fatigue (25.8%), diarrhoea (25.8%), nausea (18.2%), and chromaturia (18.2%). Four (6.1%) patients had Grade 3 toxicity and one (1.5%) patient had Grade 4 toxicity. Enzastaurin demonstrated limited clinical activity in grade 1 or 2 FL. Patients with low PKCβ2 expression in tumours had higher ORR than those with high PKCβ2 expression. Enzastaurin was well tolerated with mostly grade 1 or 2 toxicities. Further studies may be warranted in select patient populations.
Collapse
|
4
|
Wahlin BE, Sundström C, Sander B, Christensson B, Jeppsson-Ahlberg Å, Hjalmarsson E, Holte H, Østenstad B, Brown PD, Smeland EB, Kimby E. Higher World Health Organization grades of follicular lymphoma correlate with better outcome in two Nordic Lymphoma Group trials of rituximab without chemotherapy. Leuk Lymphoma 2013; 55:288-95. [PMID: 23662992 DOI: 10.3109/10428194.2013.802778] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract A common treatment for follicular lymphoma is rituximab monotherapy. To identify patients for whom this regimen is adequate as first-line therapy, we applied the World Health Organization (WHO) classification for grading follicular lymphoma in a prospective central pathology review of the biopsies of previously untreated patients in two randomized trials of rituximab without chemotherapy. In the first trial (n₁ = 53), higher WHO grades correlated with longer time to next treatment, independently of clinical prognostic factors (p = 0.030); the finding was replicated in the second trial (n₂ = 221; p = 0.019). Higher grades were associated with better treatment responses (p = 0.018). Furthermore, also grades externally confirmed by independent local pathologists correlated with time to next treatment (p = 0.048). Flow cytometry in a separate patient series showed that the intensity of CD20 increased with the malignant cell size (p < 0.00005). In conclusion, WHO grade 1 follicular lymphoma correlates with inferior outcome after rituximab monotherapy. WHO grading might provide a clinically useful tool for personalized therapy.
Collapse
Affiliation(s)
- Björn Engelbrekt Wahlin
- Department of Medicine at Huddinge, Division of Hematology, Karolinska Institutet and The Hematology Center, Karolinska University Hospital , Stockholm , Sweden
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Czuczman MS, Leonard JP, Jung S, Johnson JL, Hsi ED, Byrd JC, Cheson BD. Phase II trial of galiximab (anti-CD80 monoclonal antibody) plus rituximab (CALGB 50402): Follicular Lymphoma International Prognostic Index (FLIPI) score is predictive of upfront immunotherapy responsiveness. Ann Oncol 2012; 23:2356-2362. [PMID: 22357442 PMCID: PMC5808680 DOI: 10.1093/annonc/mdr620] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 12/14/2011] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND This phase II CALGB trial evaluated the activity and safety of an extended induction schedule of galiximab (G) plus rituximab (R) in untreated follicular lymphoma (FL). PATIENTS AND METHODS Patients with previously untreated FL (grades 1, 2, 3a) received 4 weekly infusions of G + R, followed by an additional dose every 2 months four times. International Workshop Response Criteria were used to evaluate response. RESULTS Sixty-one patients were treated and antibody infusions were well tolerated. The overall response rate (ORR) is 72.1% (95% confidence interval 59.2% to 82.9%): 47.6% complete response (CR)/unconfirmed complete response (CRu) and 24.6% partial response. At a median follow-up time of 4.3 years (range, 0.3-5.3 years) median progression-free survival (PFS) is 2.9 years. Notably, Follicular Lymphoma International Prognostic Index (FLIPI) correlated with ORR, CR rate, and PFS, and the low-risk FLIPI group (n = 12) achieved a 92% ORR, 75% CR/CRu rate, and 75% 3-year PFS. CONCLUSIONS An extended induction schedule of G + R in previously untreated FL is well tolerated and appears particularly efficacious in those patients with low-risk FLIPI scores. In addition, this trial served as the initial platform for additional CALGB 'doublet' combination regimes of rituximab plus other novel targeted agents.
Collapse
Affiliation(s)
| | - J P Leonard
- Weill Medical College of Cornell University, New York
| | - S Jung
- CALGB Statistical Office, Duke University Medical Center, Durham
| | - J L Johnson
- CALGB Statistical Office, Duke University Medical Center, Durham
| | - E D Hsi
- Cleveland Clinic Foundation, Cleveland
| | - J C Byrd
- The Ohio State University, Columbus
| | - B D Cheson
- Lombardi Cancer Center, Georgetown University Hospital, Washington, USA
| |
Collapse
|
6
|
Conconi A, Ponzio C, Lobetti-Bodoni C, Motta M, Rancoita PM, Stathis A, Moccia AA, Mazzucchelli L, Bertoni F, Ghielmini M, Cavalli F, Zucca E. Incidence, risk factors and outcome of histological transformation in follicular lymphoma. Br J Haematol 2012; 157:188-96. [DOI: 10.1111/j.1365-2141.2012.09054.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 12/12/2011] [Indexed: 12/24/2022]
Affiliation(s)
- Annarita Conconi
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | - Carlotta Ponzio
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | | | - Maddalena Motta
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | | | - Anastasios Stathis
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | - Alden A. Moccia
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | | | - Francesco Bertoni
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | - Michele Ghielmini
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | - Franco Cavalli
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| | - Emanuele Zucca
- Oncology Institute of Southern Switzerland (IOSI); Bellinzona; Switzerland
| |
Collapse
|
7
|
Abstract
Follicular lymphoma is an indolent and usually incurable disease. It has been therefore traditionally approached either by watch and wait or with single-agent treatments. The purpose was to maintain a good quality of life for a prolonged time. More aggressive regimens, including polychemotherapy, high-dose chemotherapy with stem-cell rescue and the emergence of new cytotoxic drugs have significantly improved the remission duration but could never demonstrate an impact on overall survival. In the past decade, through the addition of drugs acting on the immune system such as interferon or rituximab, the survival of follicular lymphoma patients could be improved by the range of several years. As a consequence several clinicians believe that we are near to a cure for follicular lymphoma so that the first-line treatment should be more aggressive to reach this goal. Nevertheless, at present, none of the new strategies can be shown to cure. We believe that even in the presence of many possible treatment options, watch and wait remains a good option for many patients with follicular lymphoma. When treatment is needed, chemotherapy with rituximab is the standard even though none of the chemotherapy regimens can be shown to be superior. As quality of life remains an issue, the combination of rituximab and bendamustine, a drug with high efficacy and a favourable toxicity profile, is a good new option for patients.
Collapse
Affiliation(s)
- M Ghielmini
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
| |
Collapse
|
8
|
Kumar R, Galardy PJ, Dogan A, Rodriguez V, Khan SP. Rituximab in combination with multiagent chemotherapy for pediatric follicular lymphoma. Pediatr Blood Cancer 2011; 57:317-20. [PMID: 21462303 DOI: 10.1002/pbc.23110] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/08/2011] [Indexed: 11/09/2022]
Abstract
Given the rarity of follicular lymphoma (FL) in children, there is limited data on which to base treatment recommendations. Herein, we report our institutional experience of using rituximab with multiagent chemotherapy for pediatric FL. Six pediatric patients were diagnosed with FL from 2000 to 2009. All patients received rituximab in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) for varying durations. Five of the six patients remain in remission with a median follow-up of 31 months. Larger randomized trials are indicated to establish the efficacy of this regimen for pediatric FL patients.
Collapse
Affiliation(s)
- Riten Kumar
- Division of Pediatric Hematology Oncology, Mayo Clinic, Rochester, Minnesota 55901, USA
| | | | | | | | | |
Collapse
|
9
|
Peters AC, Duan Q, Russell JA, Duggan P, Owen C, Stewart DA. Durable event-free survival following autologous stem cell transplant for relapsed or refractory follicular lymphoma: positive impact of recent rituximab exposure and low-risk Follicular Lymphoma International Prognostic Index score. Leuk Lymphoma 2011; 52:2124-9. [DOI: 10.3109/10428194.2011.594925] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
10
|
Wahlin BE, Sundström C, Holte H, Hagberg H, Erlanson M, Nilsson-Ehle H, Lindén O, Nordström M, Ostenstad B, Geisler CH, Brown PDN, Lehtinen T, Maisenhölder M, Tierens AM, Sander B, Christensson B, Kimby E. T cells in tumors and blood predict outcome in follicular lymphoma treated with rituximab. Clin Cancer Res 2011; 17:4136-44. [PMID: 21518780 DOI: 10.1158/1078-0432.ccr-11-0264] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE T cells influence outcome in follicular lymphoma, but their contributions seem to be modified by therapy. Their impact in patients receiving rituximab without chemotherapy is unknown. EXPERIMENTAL DESIGN Using flow cytometry, we evaluated the T cells in tumors and/or blood in a total of 250 follicular lymphoma patients included in two Nordic Lymphoma Group randomized trials that compared single rituximab with IFN-α2a-rituximab combinations. RESULTS In univariate analysis, higher levels of CD3(+), CD4(+), and CD8(+) T cells in both tumors and blood correlated with superior treatment responses, and in multivariate analysis, tumor-CD3(+) (P = 0.011) and blood-CD4(+) (P = 0.029) cells were independent. CD4(+) cells were favorable regardless of treatment arm, but CD8(+) cells were favorable only in patients treated with single rituximab, because IFN-α2a improved responses especially in patients with low CD8(+) cell levels. Higher levels of blood-CD3(+) (P = 0.003) and blood-CD4(+) (P = 0.046) cells predicted longer overall survival, and higher levels of blood-CD8(+) cells longer times to next treatment (P = 0.046). CONCLUSIONS We conclude that therapeutic effects of rituximab are augmented by tumor-associated T cells for rapid responses and by systemic T cells for sustained responses. CD4(+) and CD8(+) cells are both favorable in patients treated with rituximab. IFN-α2a abrogates the negative impact of few CD8(+) cells.
Collapse
Affiliation(s)
- Björn Engelbrekt Wahlin
- Division of Hematology, Department of Medicine at Huddinge, Division of Hematology, Department of Medicine at Solna, Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Norway.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Yanai S, Nakamura S, Takeshita M, Fujita K, Hirahashi M, Kawasaki K, Kurahara K, Sakai Y, Matsumoto T. Translocation t(14;18)/IGH-BCL2 in gastrointestinal follicular lymphoma: correlation with clinicopathologic features in 48 patients. Cancer 2010; 117:2467-77. [PMID: 24048795 DOI: 10.1002/cncr.25811] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 10/16/2010] [Accepted: 10/28/2010] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chromosomal translocation t(14;18)(q32;q21) involving the immunoglobulin heavy chain gene (IGH) and the BCL2 gene (t[14;18][q32;q21]/IGH-BCL2) is present in 60% to 90% of nodal follicular lymphomas. To the authors' knowledge, the prevalence and clinical significance of this translocation have not been examined previously in gastrointestinal follicular lymphomas. METHODS Clinicopathologic and molecular features were investigated in 48 patients who had gastrointestinal follicular lymphoma. The site of involvement was the duodenum in 54% of patients, the jejunum in 52%, the ileum in 52%, the stomach in 29%, and the colorectum in 15%. The presence of the t(14;18)/IGH-BCL2 translocation was detected by interphase fluorescence in situ hybridization. RESULTS Treatment modalities included surgical resection (n = 16), rituximab plus chemotherapy (n = 13), rituximab alone (n = 6), antibiotics (n = 5), and watchful waiting (n = 8). Complete remission (CR) of lymphoma was achieved in 31 patients (65%). The overall survival and event-free survival rates after 5 years were 93% and 68%, respectively. The t(14;18)/IGH-BCL2 was detected in 39 patients (81%). The involvement of multiple sites (69% vs 0%), manifestation of the lymphomatous polyposis type (72% vs 22%), and histologic grade 1 or 2 tumors (92% vs 56%) were more frequent in the t(14;18)-positive group than in the negative group. In addition, the CR rate was lower in the t(14;18)-positive group than in the negative group (56% vs 100%; P = .0179), and a trend was observed toward poorer event-free survival in the positive group (P = .089). CONCLUSIONS The t(14;18)/IGH-BCL2 chromosomal translocation occurred frequently in gastrointestinal follicular lymphomas. The current results indicated that this translocation may be a predictor of an adverse clinical course.
Collapse
Affiliation(s)
- Shunichi Yanai
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Baldo P, Rupolo M, Compagnoni A, Lazzarini R, Bearz A, Cannizzaro R, Spazzapan S, Truccolo I, Moja L. Interferon-alpha for maintenance of follicular lymphoma. Cochrane Database Syst Rev 2010:CD004629. [PMID: 20091564 DOI: 10.1002/14651858.cd004629.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Indolent non-Hodgkin's lymphoma, in particular follicular lymphoma (FL), is characterized by multiple remissions and relapses. Several studies have used interferon-alpha (IFN) to control this disease, both as induction and as maintenance therapy. It is not yet clear whether IFN can be associated with a survival benefit although it may prolong progression-free survival. OBJECTIVES To determine the effects of IFN in the maintenance therapy of FL. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2008), MEDLINE (1966 to 2008), DARE (1990 to 2008), SCOPUS (searched December 2008) and Current Contents (1975 to 2008). . SELECTION CRITERIA Randomised controlled trials of IFN versus no intervention or placebo, or IFN plus chemotherapy versus chemotherapy alone, in a maintenance setting in patients with non-Hodgkin's FL. Primary outcomes were overall survival and progression-free survival. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse events information from the trials. MAIN RESULTS We included eight trials (1563 patients). The drug was IFN alfa-2b in six trials and alfa-2a in two. Trials were heterogeneous in terms of diagnosis of FL, using several classification systems. IFN had been compared with placebo/no intervention in five trials and other chemotherapy in three. The effect of IFN was similar to that of placebo on overall survival (hazard ratio (HR) 0.90, 95% CI 0.61 to 1.34) whereas IFN was more effective when added to chemotherapy (HR 0.68, 95% confidence interval (CI) 0.52 to 0.90). Considering IFN versus all comparators, IFN was effective in prolonging progression-free survival (HR 0.66, 95% CI 0.57 to 0.77) and overall survival (fixed effects HR 0.79, 95% CI 0.67 to 0.94, I(2) = 52%). After adjustment for heterogeneity this statistically significance disappeared (random effects HR 0.82, 95% CI 0.63 to 1.08). Toxicity and patients lost to follow up were significantly higher in the IFN groups. AUTHORS' CONCLUSIONS There is evidence that addition of IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident. In the included studies, IFN was associated with significant toxicities that may have a major impact on a patient's quality of life.
Collapse
Affiliation(s)
- Paolo Baldo
- Pharmacy Unit, Drug Information Centre, CRO Aviano - Centro di Riferimento Oncologico IRCCS, Via Franco Gallini, 2, Aviano (PN), Friuli-Venezia-Giulia, Italy, 33081
| | | | | | | | | | | | | | | | | |
Collapse
|