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Bou Zeid N, Yazbeck V. PI3k Inhibitors in NHL and CLL: An Unfulfilled Promise. Blood Lymphat Cancer 2023; 13:1-12. [PMID: 36919100 PMCID: PMC10008402 DOI: 10.2147/blctt.s309171] [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: 09/06/2022] [Accepted: 01/22/2023] [Indexed: 03/09/2023]
Abstract
Phosphatidylinositol 3-kinases (PI3Ks) are a family of intracellular signal transducer enzymes that can attach a phosphate group to the 3'-hydroxyl of the inositol moiety of membrane-embedded phosphatidylinositol (PI). PI3Ks have been shown to play important roles in cell proliferation, growth, survival, motility, and metabolism. Nonetheless, the PI3K pathway has also shown to be overactivated in several tumors, particularly B-cell malignancies. In recent years, the PI3K signaling pathway has become the major focus of substantial drug discovery and development efforts. Selective (PI3K) inhibitors have been approved for the treatment of chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL), and indolent non-Hodgkin lymphomas (iNHL), such as follicular lymphoma and marginal-zone lymphoma. Four selective PI3K inhibitors have received accelerated FDA approvals for the treatment of patients with relapsed/refractory (R/R) CLL and/or iNHL based mainly on single-arm Phase II studies: Idelalisib (PI3K-δ inhibitor), copanlisib (dual PI3K-α and PI3K-δ inhibitor), duvelisib (dual PI3K-γ and PI3K-δ inhibitor), and umbralisib (dual PI3Kδ and CK1ε inhibitor). Conversely, recent interim results of randomized control trials (RCTs) involving some of these agents, showed a worrisome trend of decrease in overall survival (OS), and an increase in fatal and severe adverse effects, in comparison with patients in the control arms. Consequently, the class of PI3K inhibitors came under scrutiny, with an FDA expert panel voting on April 21, 2022, recommending that future FDA approvals of PI3K inhibitors be supported by randomized data, rather than single-arm data only, and further discontinuing the use of almost all the PI3K inhibitors in hematologic malignancies. As we believe further research is needed to help potentialize PI3K inhibitors by improving their safety profiles, this mini-review aims at revisiting the clinical successes, the failures, and the promising aspect of this class of drugs, while presenting possible ways that could benefit its successful development.
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Affiliation(s)
- Naji Bou Zeid
- Hôtel-Dieu de France Hospital, Saint Joseph University of Beirut, Beirut, Lebanon
| | - Victor Yazbeck
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
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Yazbeck V, Alesi E, Myers J, Hackney MH, Cuttino L, Gewirtz DA. An overview of chemotoxicity and radiation toxicity in cancer therapy. Adv Cancer Res 2022; 155:1-27. [DOI: 10.1016/bs.acr.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Willard P, McKay J, Yazbeck V. Role of antibody-based therapy in indolent non-Hodgkin's lymphoma. Leuk Res Rep 2021; 16:100275. [PMID: 34765437 PMCID: PMC8569585 DOI: 10.1016/j.lrr.2021.100275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/16/2021] [Indexed: 12/01/2022] Open
Abstract
Monoclonal antibodies (mAb) for indolent non-Hodgkin's lymphoma (iNHL) including follicular and marginal zone lymphomas was a key therapeutic development that changed the natural history of these diseases. Rituximab, a chimeric anti-CD20 mAb, was the first immunotherapy ever used in cancer, and a current cornerstone of lymphoma therapies. Since, we saw development of humanized antibodies, next generations anti-CD20, mAbs targeting other markers on tumor cells (CD19 and CD22), its microenvironment (PD-1, CD47), antibody drug conjugates and bispecific T cell engagers. Given their activity, safety and specificity, mAbs are well poised to remain an essential therapeutic tool for iNHL and other malignancies.
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Affiliation(s)
- Patrick Willard
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States of America
| | - John McKay
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States of America
| | - Victor Yazbeck
- Virginia Commonwealth University, Department of Internal Medicine, Richmond, VA, United States of America.,Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, United States of America
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Al-Juhaishi T, Ahmed S. CAR-T in B-Cell Lymphomas: The Past, Present, and Future. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e261-e268. [PMID: 34782260 DOI: 10.1016/j.clml.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/27/2021] [Accepted: 10/09/2021] [Indexed: 01/01/2023]
Abstract
Aggressive B-cell lymphomas including diffuse large B-cell lymphoma make up the majority of non-Hodgkin's lymphoma globally. While more than half of these patients can be cured with modern chemoimmunotherapy regimens, the outcomes of relapsed or refractory disease continue to be very poor. Despite significant developments in targeted cancer therapies and immuno-oncology, the attainability of a cure remained an elusive goal outside of incorporating high doses of chemotherapy followed by hematopoietic stem cell transplantation, for patients who have chemosensitive disease. The development of chimeric antigen receptor T-cell therapy changed that paradigm and introduced a new field of therapeutic possibilities for these patients. In this review, we will discuss the current state of this therapeutic modality in B-cell lymphomas and provide opinions on where future efforts need to focus in order to further improve their clinical utility.
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Affiliation(s)
| | - Sairah Ahmed
- University of Texas MD Anderson Cancer Center, Houston, TX
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Al-Juhaishi T, Mckay J, Sindel A, Yazbeck V. Perspectives on chemotherapy for the management of double-hit lymphoma. Expert Opin Pharmacother 2020; 21:653-661. [PMID: 32066288 DOI: 10.1080/14656566.2020.1727445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION . Unlike most B-cell lymphomas, they have poor response to standard R-CHOP therapy, tend to quickly develop resistance to cytotoxic chemotherapies, and are associated with higher central nervous system (CNS) infiltration. This can lead to increased risk of relapse and worse prognosis. DHL/THL represent a subset of lymphomas with unmet medical need. AREA COVERED The authors present the available data for the current treatment regimens including intensive chemotherapy regimens, hematopoietic stem-cell transplantation (HSCT), and CNS prophylaxis. They also discuss treatment for relapsed disease including targeted therapies. EXPERT OPINION There is currently no accepted standard of care for DHL/THL. For frontline therapy, we recommend enrollment in a well-designed clinical trial if possible, otherwise DA-EPOCH-R with CNS prophylaxis is a commonly used first-line therapy. The authors recommend close surveillance for patients achieving complete response, but for those who fail to achieve a complete response, then clinical trials, more aggressive salvage chemotherapy regimens, or cellular therapies are usually considered.
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Affiliation(s)
- Taha Al-Juhaishi
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA
| | - John Mckay
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA
| | - Ariel Sindel
- Massey Cancer Center, Virginia Commonwealth University , Richmond, VA, USA
| | - Victor Yazbeck
- Department of Medicine, Division of Hematology, Oncology and Palliative Care, Virginia Commonwealth University , Richmond, VA, USA.,Massey Cancer Center, Virginia Commonwealth University , Richmond, VA, USA
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Sindel A, Al-Juhaishi T, Yazbeck V. Marginal Zone Lymphoma: State-of-the-Art Treatment. Curr Treat Options Oncol 2019; 20:90. [PMID: 31807935 DOI: 10.1007/s11864-019-0687-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT Despite being the second most common indolent non-Hodgkin's lymphoma (iNHL), marginal zone lymphoma (MZL) remains largely understudied, and given its underlying disease heterogeneity, it is challenging to define a single treatment approach for these patients. For localized disease, local therapy is recommended such as triple therapy for H. pylori in gastric extranodal MZL, splenectomy for splenic MZL, and radiotherapy for nodal MZL. For disseminated disease with low tumor burden, a watch and wait or single-agent rituximab can be used. However, for symptomatic disease, a similar approach to follicular lymphoma (FL) can be used with chemoimmunotherapy approaches such as bendamustine and rituximab. High FDG uptake is not common in MZL and is not diagnostic by itself of transformation to high-grade lymphoma but informs the choice of the site to be biopsied. Transformation into a large B cell lymphoma is treated with R-CHOP-like regimens. Patients with relapsing disease after at least one CD20-based therapy have several recently approved chemotherapy-free options including B cell receptor inhibitors such ibrutinib (approved specifically in MZL) and immunomodulatory agents such as lenalidomide and rituximab (FDA approved in MZL and FL). Phosphoinositide 3-kinase (PI3K) inhibitors have shown excellent activity in iNHL, specifically in MZL, with breakthrough designation status for copanlisib and umbralisib, allowing off label use of this class of agents in clinical practice. With the availability of prospective clinical trials using chemo-free approaches, specifically those targeting abnormal signaling pathways activated in MZL tumors and its microenvironment, treating physicians are encouraged to enroll patients on these clinical trials in order to better understand the underlying biology, mechanisms of response, and resistance to current therapies and help design future rationale combination strategies.
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Affiliation(s)
- Ariel Sindel
- Department of Internal Medicine, Virginia Commonwealth University, 401 College Street, Box 980035, Richmond, VA, 23298, USA
| | - Taha Al-Juhaishi
- Department of Internal Medicine, Virginia Commonwealth University, 401 College Street, Box 980035, Richmond, VA, 23298, USA
| | - Victor Yazbeck
- Department of Internal Medicine, Virginia Commonwealth University, 401 College Street, Box 980035, Richmond, VA, 23298, USA. .,Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA.
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Crisci S, Di Francia R, Mele S, Vitale P, Ronga G, De Filippi R, Berretta M, Rossi P, Pinto A. Overview of Targeted Drugs for Mature B-Cell Non-hodgkin Lymphomas. Front Oncol 2019; 9:443. [PMID: 31214498 PMCID: PMC6558009 DOI: 10.3389/fonc.2019.00443] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/09/2019] [Indexed: 12/15/2022] Open
Abstract
The improved knowledge of pathogenetic mechanisms underlying lymphomagenesis and the discovery of the critical role of tumor microenvironments have enabled the design of new drugs against cell targets and pathways. The Food and Drug Administration (FDA) has approved several monoclonal antibodies (mAbs) and small molecule inhibitors (SMIs) for targeted therapy in hematology. This review focuses on the efficacy results of the currently available targeted agents and recaps the main ongoing trials in the setting of mature B-Cell non-Hodgkin lymphomas. The objective is to summarize the different classes of novel agents approved for mature B-cell lymphomas, to describe in synoptic tables the results they achieved and, finally, to draw future scenarios as we glimpse through the ongoing clinical trials. Characteristics and therapeutic efficacy are summarized for the currently approved mAbs [i.e., anti-Cluster of differentiation (CD) mAbs, immune checkpoint inhibitors, chimeric antigen receptor (CAR) T-cell therapy, and bispecific antibodies] as well as for SMIs i.e., inhibitors of B-cell receptor signaling, proteasome, mTOR BCL-2 HDAC pathways. The biological disease profiling of B-cell lymphoma subtypes may foster the discovery of innovative drug strategies for improving survival outcome in lymphoid neoplasms, as well as the trade-offs between efficacy and toxicity. The hope for clinical advantages should carefully be coupled with mindful awareness of the potential pitfalls and the occurrence of uneven, sometimes severe, toxicities.
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Affiliation(s)
- Stefania Crisci
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
| | - Raffaele Di Francia
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
| | - Sara Mele
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
| | - Pasquale Vitale
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
| | - Giuseppina Ronga
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
| | - Rosaria De Filippi
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Paola Rossi
- Department of Biology and Biotechnology “L. Spallanzani,” University of Pavia, Pavia, Italy
| | - Antonio Pinto
- Hematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori, Fondazione “G. Pascale” IRCCS, Naples, Italy
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