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Wang W, Chen H, Ju W, Yang W, Ding G, Wang L. A rare case of Richter transformation with breast involvement: A case report and literature review. Open Life Sci 2024; 19:20220889. [PMID: 38911930 PMCID: PMC11193393 DOI: 10.1515/biol-2022-0889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/01/2024] [Accepted: 05/09/2024] [Indexed: 06/25/2024] Open
Abstract
Richter transformation (RT) represents the development of intrusive lymphoma in individuals previously or concurrently diagnosed with chronic lymphocytic leukemia (CLL) and is characterized by lymph node enlargement. However, cases involving extra-nodal organ involvement as the first symptom are rare. There are no reports of RT with breast lesions as the first symptom. Nonspecific and atypical clinical manifestations represent key challenges in the accurate diagnosis and appropriate treatment of RT. This case report describes an elderly female patient who presented with breast lesions as the first RT symptom. The patient was admitted with a painless mass in the left breast. Examination revealed multiple lymphadenopathies and abnormally high white blood cell levels. The patient was diagnosed with CLL after hematological tests, assessments of bone marrow morphology, and tissue biopsy. Mammography and B-ultrasonography showed solid space-occupying lesions (BI-RADS category 5) in the left breast. Initially, the patient declined a breast biopsy and was therefore prescribed ibrupotinib treatment, which showed limited efficacy. A needle biopsy of the affected breast indicated the presence of diffuse large B-cell lymphoma. Based on auxiliary and pathological examinations and medical history, the final diagnosis was RT with breast involvement. Zanubrutinib with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone treatment provided initial control; however, the treatment strategy required adjustment because of the patient's fluctuating condition. The current status of the patient is marked as stable, showing an overall achievement of partial alleviation. The patient is in the process of receiving follow-up treatment. We also performed a comprehensive literature review on RT, with particular emphasis on its biological paradigm, prognosis implications, existing therapeutic approaches, and emerging directions in treatment modalities.
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Affiliation(s)
- Wenhui Wang
- Department of Pathology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Hao Chen
- Department of Pathology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Wendong Ju
- Department of Oncology and Hematology, Zhongshan Boai Hospital Affiliated to Southern Medical University, Zhongshan528403, Guangdong, China
| | - Weihong Yang
- Department of Pathology, Zhongshan Boai Hospital Affiliated to Southern Medical University, Zhongshan,
Guangdong, China
| | - Gaoming Ding
- Department of Oncology and Hematology, Zhongshan Boai Hospital Affiliated to Southern Medical University, Zhongshan528403, Guangdong, China
| | - Li Wang
- Department of Oncology and Hematology, Zhongshan Boai Hospital Affiliated to Southern Medical University, 6 Chenggui Road, East District, Zhongshan, 528403, Guangdong, China
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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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Shang J, Hu S, Wang X. Targeting natural killer cells: from basic biology to clinical application in hematologic malignancies. Exp Hematol Oncol 2024; 13:21. [PMID: 38396050 PMCID: PMC10885621 DOI: 10.1186/s40164-024-00481-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
Natural killer (NK) cell belongs to innate lymphoid cell family that contributes to host immunosurveillance and defense without pre-immunization. Emerging studies have sought to understand the underlying mechanism behind NK cell dysfunction in tumor environments, and provide numerous novel therapeutic targets for tumor treatment. Strategies to enhance functional activities of NK cell have exhibited promising efficacy and favorable tolerance in clinical treatment of tumor patients, such as immune checkpoint blockade (ICB), chimeric antigen receptor NK (CAR-NK) cell, and bi/trispecific killer cell engager (BiKE/TriKE). Immunotherapy targeting NK cell provides remarkable advantages compared to T cell therapy, including a decreased rate of graft versus-host disease (GvHD) and neurotoxicity. Nevertheless, advanced details on how to support the maintenance and function of NK cell to obtain better response rate and longer duration still remain to be elucidated. This review systematically summarizes the profound role of NK cells in tumor development, highlights up-to-date advances and current challenges of therapy targeting NK cell in the clinical treatment of hematologic malignancies.
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Affiliation(s)
- Juanjuan Shang
- Department of Hematology, Shandong Provincial Hospital, Shandong University, No.324, Jingwu Road, Jinan, 250021, Shandong, China
| | - Shunfeng Hu
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Shandong University, No.324, Jingwu Road, Jinan, 250021, Shandong, China.
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, Shandong, China.
- Taishan Scholars Program of Shandong Province, Jinan, 250021, Shandong, China.
- Branch of National Clinical Research Center for Hematologic Diseases, Jinan, 250021, Shandong, China.
- National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, 251006, China.
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Bennett R, Seymour JF. Update on the management of relapsed/refractory chronic lymphocytic leukemia. Blood Cancer J 2024; 14:33. [PMID: 38378673 PMCID: PMC10879527 DOI: 10.1038/s41408-024-01001-1] [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: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
Chronic lymphocytic leukemia (CLL) predominantly affects older adults, characterized by a relapsing and remitting pattern with sequential treatments available for many patients. Identification of progressive/relapsed CLL should prompt close monitoring and early discussion about the next therapies when treatment indications are present. The intervening period represents an opportunity to optimize patient health, including establishing adequate vaccination and surveillance for second primary malignancies, and treating non-CLL-related comorbidities which may impact well-being and CLL therapy. We now see patients with relapsed/refractory (RR) CLL in the clinic who have been previously treated with chemoimmunotherapy (CIT) and/or one or more novel therapies. Continuous covalent inhibitors of Bruton's tyrosine kinase (cBTKi) and fixed-duration venetoclax (Ven)-anti-CD20 monoclonal antibody (mAb) are preferred over CIT given the survival advantages associated with these therapies, although have never been evaluated head-to-head. While both classes are effective for RR CLL, potential side effects and the logistics of administration differ. Few randomized data demonstrate the sequential use of cBTKi and fixed-duration Ven-anti-CD20 mAb; however, they may be used in either sequence. Newer non-covalent BTKi, active against BTK C481 resistance mutations emerging with continuous cBTKi exposure, and novel approaches such as BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell therapies demonstrate impressive efficacy. In this review of RR CLL we explore relevant investigations, consideration of broader CLL- and non-CLL-related health needs, and evidence for efficacy and safety of B-cell receptor inhibitors and Ven, including available data to support drug sequencing or switching. We describe novel approaches to RR CLL, including rechallenging with fixed-duration therapies, allogeneic stem cell transplant indications in the novel therapy era, and highlight early data supporting the use of T-cell directing therapies and novel drug targets.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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Al-Sawaf O, Ligtvoet R, Robrecht S, Stumpf J, Fink AM, Tausch E, Schneider C, Boettcher S, Mikusko M, Ritgen M, Schetelig J, von Tresckow J, Vehling-Kaiser U, Gaska T, Wendtner CM, Chapuy B, Fischer K, Kreuzer KA, Stilgenbauer S, Staber P, Niemann C, Hallek M, Eichhorst B. Tislelizumab plus zanubrutinib for Richter transformation: the phase 2 RT1 trial. Nat Med 2024; 30:240-248. [PMID: 38071379 PMCID: PMC10803258 DOI: 10.1038/s41591-023-02722-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/15/2023] [Indexed: 01/24/2024]
Abstract
In patients with chronic lymphocytic leukemia, Richter transformation (RT) reflects the development of an aggressive lymphoma that is associated with poor response to chemotherapy and short survival. We initiated an international, investigator-initiated, prospective, open-label phase 2 study in which patients with RT received a combination of the PD-1 inhibitor tislelizumab plus the BTK inhibitor zanubrutinib for 12 cycles. Patients responding to treatment underwent maintenance treatment with both agents. The primary end point was overall response rate after six cycles. Of 59 enrolled patients, 48 patients received at least two cycles of treatment and comprised the analysis population according to the study protocol. The median observation time was 13.9 months, the median age was 67 (range 45-82) years. Ten patients (20.8%) had received previous RT-directed therapy. In total, 28 out of 48 patients responded to induction therapy with an overall response rate of 58.3% (95% confidence interval (CI) 43.2-72.4), including 9 (18.8%) complete reponse and 19 (39.6%) partial response, meeting the study's primary end point by rejecting the predefined null hypothesis of 40% (P = 0.008). Secondary end points included duration of response, progression-free survival and overall survival. The median duration of response was not reached, the median progression-free survival was 10.0 months (95% CI 3.8-16.3). Median overall survival was not reached with a 12-month overall survival rate of 74.7% (95% CI 58.4-91.0). The most common adverse events were infections (18.0%), gastrointestinal disorders (13.0%) and hematological toxicities (11.4%). These data suggest that combined checkpoint and BTK inhibition by tislelizumab plus zanubrutinib is an effective and well-tolerated treatment strategy for patients with RT. ClinicalTrials.gov Identifier: NCT04271956 .
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Affiliation(s)
- Othman Al-Sawaf
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany.
- Francis Crick Institute London, London, UK.
- Cancer Institute, University College London, London, UK.
| | - Rudy Ligtvoet
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Janina Stumpf
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Anna-Maria Fink
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Eugen Tausch
- Department III of Internal Medicine, University Hospital Ulm, Ulm, Germany
| | - Christof Schneider
- Department III of Internal Medicine, University Hospital Ulm, Ulm, Germany
| | - Sebastian Boettcher
- Department III of Internal Medicine, University Hospital Rostock, Rostock, Germany
| | - Martin Mikusko
- Department of Haematology and Oncology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Matthias Ritgen
- Department II of Internal Medicine, Campus Kiel, University of Schleswig-Holstein, Kiel, Germany
| | - Johannes Schetelig
- Department I of Internal Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Tobias Gaska
- Department of Hematology and Oncology, Brüderkrankenhaus St. Josef, Paderborn, Germany
| | | | - Bjoern Chapuy
- Department of Hematology and Medical Oncology, Georg-August University Göttingen, Göttingen, Germany
- Department of Hematology, Oncology, and Cancer Immunology, Charité -University Medical Center Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Karl-Anton Kreuzer
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | | | - Philipp Staber
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Carsten Niemann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | - Michael Hallek
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and German CLL Study Group; Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany.
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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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Katsuya H, Suzumiya J, Kimura S. Clinical PD-1/PD-L1 Blockades in Combination Therapies for Lymphomas. Cancers (Basel) 2023; 15:5399. [PMID: 38001659 PMCID: PMC10670854 DOI: 10.3390/cancers15225399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
Immunotherapy with the programmed cell death protein 1 (PD-1)/PD-1 ligand (PD-L1) blockade has revolutionized the treatment of advanced solid cancers. However, these clinical benefits have been limited to cases of malignant lymphomas, showing promising results for only classic Hodgkin lymphoma (cHL) and primary mediastinal B-cell lymphoma (PMBCL). To bring clinical benefits to more patients with lymphoma, numerous combination therapies involving PD-1/PD-L1 blockade have been tested in clinical trials in both frontline and relapsed/refractory settings. This article reviews the current landscape of combination therapies with PD-1/PD-L1 blockade for lymphoma and discusses the potential therapeutic approaches. An interim analysis of a phase 3 study demonstrated increased progression-free survival with nivolumab combination therapy over the current frontline treatment in patients with advanced-stage cHL. The results of combination therapies for aggressive B-cell lymphomas, except for PMBCL, have been disappointing. Several clinical trials of combined PD-1/PD-L1 blockade and Bruton's tyrosine kinase inhibitors are exploring its efficacy in patients with chronic lymphocytic leukemia (CLL) with Richter transformation. Several T-cell lymphoma subtypes respond to PD-1/PD-L1 blockade monotherapy. Further clinical trials are underway to investigate appropriate combination regimens with PD-1/PD-L1 blockade, especially for cHL, CLL with Richter transformation, and T-cell lymphoma, in both frontline and relapsed/refractory settings.
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Affiliation(s)
- Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
| | - Junji Suzumiya
- Department of Hematology, Koga Community Hospital, Yaizu 425-0088, Japan;
| | - Shinya Kimura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga 849-8501, Japan
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Abrisqueta P, Nadeu F, Bosch-Schips J, Iacoboni G, Serna A, Cabirta A, Yáñez L, Quintanilla-Martínez L, Bosch F. From genetics to therapy: Unraveling the complexities of Richter transformation in chronic lymphocytic leukemia. Cancer Treat Rev 2023; 120:102619. [PMID: 37660626 DOI: 10.1016/j.ctrv.2023.102619] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/05/2023]
Abstract
Richter transformation (RT) refers to the progression of chronic lymphocytic leukemia, the most prevalent leukemia among adults, into a highly aggressive lymphoproliferative disorder, primarily a diffuse large B-cell lymphoma. This is a severe complication that continues to be a therapeutic challenge and remains an unmet medical need. Over the last five years, significant advances have occurred in uncovering the biological processes leading to the RT, refining criteria for properly diagnose RT from other entities, and exploring new therapeutic options beyond the ineffective chemotherapy. This review summarizes current knowledge in RT, including recent advances in the understanding of the pathogenesis of RT, in the classification of RT, and in the development of novel therapeutic strategies for this grave complication.
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Affiliation(s)
- Pau Abrisqueta
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Ferran Nadeu
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain
| | - Jan Bosch-Schips
- Department of Pathology, Hospital Universitari de Bellvitge-Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Gloria Iacoboni
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Angel Serna
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Alba Cabirta
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, Spain
| | - Lucrecia Yáñez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Leticia Quintanilla-Martínez
- Institute of Pathology and Neuropathology, Tübingen University Hospital and Comprehensive Cancer Center Tübingen-Stuttgart, 72076 Tübingen, Germany
| | - Francesc Bosch
- Department of Hematology, Vall d'Hebron Hospital Universitari, Experimental Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, 08193 Bellaterra, 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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Mertowska P, Mertowski S, Smolak K, Kita A, Kita G, Guz K, Pasiarski M, Grywalska E. Immune Checkpoint Pathway Expression in Lymphocyte Subpopulations in Patients with Common Variable Immunodeficiency and Chronic Lymphocytic Leukemia. Cancers (Basel) 2023; 15:5184. [PMID: 37958359 PMCID: PMC10649987 DOI: 10.3390/cancers15215184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
This study aims to gain a deeper understanding of chronic lymphocytic leukemia (CLL) and common variable immunodeficiency (CVID) by studying immune cells and specific immune checkpoint signaling pathways. The analysis of the percentage of selected immune points and their ligands (PD-1/PD-L1, CTLA-4/CD86, and CD200R/CD200) on peripheral blood lymphocyte subpopulations was performed using flow cytometry, and additional analyses determining the serum concentration of the above-mentioned molecules were performed using enzyme immunoassay tests. The obtained results indicate several significant changes in the percentage of almost all tested molecules on selected subpopulations of T and B lymphocytes in both CVID and CLL patients in relation to healthy volunteers and between the disease subunits themselves. The results obtained were also supported by the analysis of the serum concentration of soluble molecules tested. By uncovering valuable insights, we hope to enhance our comprehension and management of these conditions, considering both immunodeficiencies and hematological malignancies. Understanding the role of these signaling pathways in disease development and progression may lead to the development of modern, personalized diagnostic and therapeutic strategies. Ultimately, this knowledge may enable the monitoring of the immune system in patients with CVID and CLL, paving the way for improved patient care in the future.
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Affiliation(s)
- Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
| | - Sebastian Mertowski
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
| | - Konrad Smolak
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
| | - Aleksandra Kita
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Gabriela Kita
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Katarzyna Guz
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Marcin Pasiarski
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.)
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11
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Ravindran A, Dasari S, Ruan GJ, Artymiuk CJ, He R, Viswanatha DS, Abeykoon JP, Zanwar S, Young JR, Goyal G, Go RS, Rech KL. Malignant Histiocytosis Comprises a Phenotypic Spectrum That Parallels the Lineage Differentiation of Monocytes, Macrophages, Dendritic Cells, and Langerhans Cells. Mod Pathol 2023; 36:100268. [PMID: 37406859 DOI: 10.1016/j.modpat.2023.100268] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
Malignant histiocytoses (MHs), or the 'M group' of the Histiocyte Society classification, are characterized by neoplastic histiocytes with large pleomorphic nuclei. MH encompasses the diagnoses of histiocytic sarcoma, interdigitating dendritic cell sarcoma, and Langerhans cell sarcoma. We aimed to define the phenotypic spectrum of MH and examine the genotypic features across this spectrum. Using immunohistochemistry, we arranged the 22 cases into 4 subtypes that correspond to the lines of differentiation from monocytic and dendritic cell precursors as follows: (1) macrophage (n = 5): CD68+, CD163+, CD14+, and Factor 13a+; (2) monocyte-macrophage (n = 5): CD68+, CD163+, CD14+, S100+, and OCT2+; (3) dendritic cell (n = 6): CD68+, CD11c+, S100+, lysozyme+, ZBTB46+, and CD1a/langerin < 5%; and (4) Langerhans cell (n = 6): CD68+, CD11c+, S100+, ZBTB46+, CD1a+, and langerin+. The phenotypic subtypes align with those seen in low-grade histiocytic neoplasms as follows: MH-macrophage type correlates with Erdheim-Chester disease phenotype; MH-monocyte-macrophage type with Rosai-Dorfman disease phenotype, and MH-Langerhans cell type with Langerhans cell histiocytosis. Activating mutations in MAPK-pathway genes were identified in 80% of MH cases; 29% had mutations in the PI3k-AKT-mTOR pathway and 59% had mutations in epigenetic modulating genes. Strong expression of cyclin D1 was present in all cases, whereas p-ERK and p-AKT were not uniformly expressed. Eight of 22 (36%) MH cases were proven to be clonally related to a prior B-cell lymphoma. Defining the phenotypic spectrum of MH provides a guide to diagnosis and allows further exploration into the potential biological and clinical significance.
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Affiliation(s)
- Aishwarya Ravindran
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; Division of Laboratory Medicine-Hematopathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Surendra Dasari
- Division of Computational Biology, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Gordon J Ruan
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Cody J Artymiuk
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Rong He
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - David S Viswanatha
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jithma P Abeykoon
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Saurabh Zanwar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason R Young
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Gaurav Goyal
- Division of Hematology-Medical Oncology, The University of Alabama at Birmingham, Birmingham, Alabama; Research Collaborator (limited tenure), Mayo Clinic, Rochester, Minnesota
| | - Ronald S Go
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Karen L Rech
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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12
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Audil HY, Kosydar SR, Larson DP, Parikh SA. Richter Transformation of Chronic Lymphocytic Leukemia-Are We Making Progress? Curr Hematol Malig Rep 2023; 18:144-157. [PMID: 37294394 DOI: 10.1007/s11899-023-00701-y] [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] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW The treatment paradigm of chronic lymphocytic leukemia (CLL) has dramatically changed with the advent of novel targeted agents over the past decade. Richter transformation (RT), or the development of an aggressive lymphoma from a background of CLL, is a well-recognized complication of CLL and carries significantly poor clinical outcomes. Here, we provide an update on current diagnostics, prognostication, and contemporary treatment of RT. RECENT FINDINGS Several genetic, biologic, and laboratory markers have been proposed as candidate risk factors for the development of RT. Although a diagnosis of RT is typically suspected based on clinical and laboratory findings, tissue biopsy is essential for histopathologic confirmation of diagnosis. The standard of care for RT treatment at this time remains chemoimmunotherapy with the goal of proceeding to allogeneic stem cell transplantation in eligible patients. Several newer treatment modalities are being studied for use in the management of RT, including small molecules, immunotherapy, bispecific antibodies, and chimeric antigen receptor T-cell (CAR-T) therapy. The management of patients with RT remains a challenge. Ongoing trials show enormous promise for newer classes of therapy in RT, with the hope being that these agents can synergize, and perhaps supersede, the current standard of care in the near future.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Immunotherapy
- Biopsy
- Cell Transformation, Neoplastic/genetics
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Affiliation(s)
- Hadiyah Y Audil
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Samuel R Kosydar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel P Larson
- Division of Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - Sameer A Parikh
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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13
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Mertowska P, Mertowski S, Smolak K, Kita G, Guz K, Kita A, Pasiarski M, Smok-Kalwat J, Góźdź S, Grywalska E. Could Immune Checkpoint Disorders and EBV Reactivation Be Connected in the Development of Hematological Malignancies in Immunodeficient Patients? Cancers (Basel) 2023; 15:4786. [PMID: 37835480 PMCID: PMC10572023 DOI: 10.3390/cancers15194786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/31/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
Primary immunodeficiencies (PIDs) and secondary immunodeficiencies (SIDs) are characterized by compromised immune function, rendering individuals susceptible to infections and potentially influencing cancer development. Epstein-Barr virus (EBV), a widespread herpesvirus, has been linked to cancer, particularly in those with weakened immune systems. This study aims to compare selected immune parameters, focusing on immune checkpoint molecules (PD-1/PD-L1, CTLA-4/CD86, CD200R/CD200), and EBV reactivation in patients with chronic lymphocytic leukemia (CLL, a representative of SIDs) and common variable immunodeficiency (CVID, a representative of PIDs). We performed a correlation analysis involving patients diagnosed with CLL, CVID, and a healthy control group. EBV reactivation was assessed using specific antibody serology and viral load quantification. Peripheral blood morphology, biochemistry, and immunophenotyping were performed, with emphasis on T and B lymphocytes expressing immune checkpoints and their serum concentrations. Our findings revealed elevated EBV reactivation markers in both CLL and CVID patients compared with healthy controls, indicating increased viral activity in immunodeficient individuals. Furthermore, immune checkpoint expression analysis demonstrated significantly altered percentages of T and B lymphocytes expressing PD-1/PD-L1, CTLA-4/CD86, and CD200R/CD200 in CLL and CVID patients. This suggests a potential interplay between immune checkpoint dysregulation and EBV reactivation in the context of immunodeficiency. In conclusion, our study underscores the intricate relationship between immune dysfunction, EBV reactivation, and immune checkpoint modulation in the context of immunodeficiency-associated cancers. The altered expression of immune checkpoints, along with heightened EBV reactivation, suggests a potential mechanism for immune evasion and tumor progression. These findings provide insights into the complex interactions that contribute to cancer development in immunocompromised individuals, shedding light on potential therapeutic targets for improved management and treatment outcomes. Further investigations are warranted to elucidate the underlying mechanisms and to explore potential interventions to mitigate cancer risk in these patient populations.
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Affiliation(s)
- Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
| | - Sebastian Mertowski
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
| | - Konrad Smolak
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
| | - Gabriela Kita
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Katarzyna Guz
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Aleksandra Kita
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
- Student Research Group of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Marcin Pasiarski
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland;
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland; (J.S.-K.); (S.G.)
| | - Jolanta Smok-Kalwat
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland; (J.S.-K.); (S.G.)
| | - Stanisław Góźdź
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland; (J.S.-K.); (S.G.)
- Institute of Medical Science, Collegium Medicum, Jan Kochanowski University of Kielce, IX Wieków Kielc 19A, 25-317 Kielce, Poland
| | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (P.M.); (K.S.); (G.K.); (K.G.); (A.K.); (E.G.)
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14
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Innocenti I, Benintende G, Tomasso A, Fresa A, Autore F, Larocca LM, Laurenti L. Richter transformation in Chronic Lymphocytic Leukemia. Hematol Oncol 2023; 41:293-300. [PMID: 36433773 DOI: 10.1002/hon.3106] [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: 07/29/2022] [Revised: 11/10/2022] [Accepted: 11/19/2022] [Indexed: 11/28/2022]
Abstract
Chronic lymphocytic leukemia can evolve to an aggressive lymphoma-in most of the cases diffuse large B cells lymphoma, rarely Hodgkin lymphoma-and this complication is defined Richter syndrome (RS). Immunogenotypic features that characterize RS include unmutated IgHV status with high prevalence of IgHV4-39/D6-13/J5 sequence; deletion of chromosome 17p or 11q; activation of oncogenes as NOTCH1 and c-MYC; inactivation of onco-suppressors as TP53 and CDKN2A; high expression of CD38 in lymph-nodes. The prognosis of this condition is very poor: patients experience a rapid clinical deterioration with frequent therapeutic failure since the current options include suboptimal strategies as standard chemo-immunotherapy followed by hematopoietic stem cells transplantation or enrollment in clinical trials which investigate the efficacy of target drugs. Understanding the biology of such a heterogeneous condition is crucial to personalize the treatment and improve patient's survival.
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Affiliation(s)
- Idanna Innocenti
- Sezione di Ematologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario a. Gemelli IRCCS, Rome, Italy
| | - Giulia Benintende
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Annamaria Tomasso
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Fresa
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Autore
- Sezione di Ematologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario a. Gemelli IRCCS, Rome, Italy
| | | | - Luca Laurenti
- Sezione di Ematologia, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario a. Gemelli IRCCS, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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15
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Seymour JF. Approach to relapsed CLL including Richter Transformation. Hematol Oncol 2023; 41 Suppl 1:136-143. [PMID: 37294971 DOI: 10.1002/hon.3146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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16
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Jain N, Senapati J, Thakral B, Ferrajoli A, Thompson P, Burger J, Basu S, Kadia T, Daver N, Borthakur G, Konopleva M, Pemmaraju N, Parry E, Wu CJ, Khoury J, Bueso-Ramos C, Garg N, Wang X, Lopez W, Ayala A, O’Brien S, Kantarjian H, Keating M, Allison J, Sharma P, Wierda W. A phase 2 study of nivolumab combined with ibrutinib in patients with diffuse large B-cell Richter transformation of CLL. Blood Adv 2023; 7:1958-1966. [PMID: 36287248 PMCID: PMC10189379 DOI: 10.1182/bloodadvances.2022008790] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/11/2022] [Accepted: 10/11/2022] [Indexed: 11/20/2022] Open
Abstract
Richter transformation (RT) is a rare complication of chronic lymphocytic leukemia (CLL) that has dismal outcomes. Upregulation of PD-1/PD-L1 drives immunological evasion in patients with RT. We hypothesized that combining nivolumab, a PD-1 blocking antibody, with the BTK inhibitor (BTKi) ibrutinib could potentiate tumor-cell killing. We conducted an investigator-initiated phase 2 clinical trial to assess the efficacy of combined nivolumab and ibrutinib in patients with diffuse large B-cell lymphoma (DLBCL) RT and CLL. Patients included were ≥18 years of age with adequate hepatic and renal function. Patients received nivolumab every 2 weeks of a 4-week cycle for a maximum of 24 cycles. A standard dose ibrutinib was initiated from cycle 2 onward and continued daily until progression. For patients who were already on ibrutinib at the time of study entry, the same was continued while nivolumab was initiated. A total of 24 patients with RT with a median age of 64.5 years (range, 47-88) were enrolled. Ten patients (42%) had received prior treatment for RT and 13 patients (54%) had received a prior BTKi. A total of 10 patients (42%) responded with a median duration of response of 15 months. The median overall survival was 13 months. Four of 24 (17%) patients had checkpoint inhibition-related immunological toxicities. In the CLL cohort, 10 patients were enrolled, of whom 3 patients converted from partial to complete remission; 1 patient had a grade 2 immunological toxicity. Combined nivolumab and ibrutinib is an active regimen for patients with DLBCL RT with an overall response rate of 42%. Given the limited treatment options for patients with RT, checkpoint inhibition provides a potential therapeutic option. This trial is registered at www.clinicaltrials.gov as #NCT02420912.
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Affiliation(s)
- Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beenu Thakral
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sreyashi Basu
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erin Parry
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Catherine J. Wu
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Joseph Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carlos Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Garg
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wanda Lopez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ana Ayala
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O’Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, Orange, CA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - James Allison
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Padmanee Sharma
- Immunotherapy Platform, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Immunology, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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17
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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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18
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Immune evasion phenotype is common in Richter transformation diffuse large B-cell lymphoma variant. Virchows Arch 2023. [PMID: 36864257 DOI: 10.1007/s00428-023-03520-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Immune checkpoint inhibitors (PD-1 inhibitors) have shown clinical activity in Richter transformation-diffuse large B-cell lymphoma variant (RT-DLBCL), thus providing for a novel therapeutic approach. The study group consists of 64 patients with RT-DLBCL. Expression of PD-1, PD-L1, CD30, and microsatellite instability (MSI) status (hMLH1, hMSH2, hMSH6, PMS1) was assessed using immunohistochemistry. EBV-encoded RNA (EBER) was evaluated using colorimetric in situ hybridization. PD-1 and PD-L1 expression levels were categorized on the basis of tumor cell expression as follows: negative (< 5%), positive to low-positive (5-50%), or high-positive (> 50%). An "immune evasion phenotype" (IEP) was defined as RT-DLBCL cases having high-positive expression of PD-1 and/or PD-L1 on tumor cells. The level of PD1-positive tumor-infiltrating lymphocytes (TILs) was estimated as a fraction of total lymphocytes and categorized as negative/low vs. brisk (> 20%). 28/64 (43.7%) patients were characterized as IEP+ RT-DLBCL. A brisk level of PD1+ TILs was significantly more common in IEP1+ compared with IEP- tumors (17/28, 60.7% vs. 5/34, 14.7%; p = 0.001). In addition, CD30 expression was significantly more common in IEP+ compared with IEP- RT-DLBCL (6/20, 30% vs. 1/27, 3.7%; p = 0.0320). Two (2/36; 5.5%) cases were positive for EBER, both IEP+. There was no significant difference between the two groups in terms of age, sex, or time to transformation. Assessment of mismatch repair proteins demonstrated absence of microsatellite instability (MSI) in all cases (18/18; 100%). Notably, patients with brisk PD1+ TILs had a significantly better OS compared to those with a negative/low infiltrate (p = 0.0285).
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19
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El Hussein S, Medeiros LJ, Lyapichev KA, Fang H, Jelloul FZ, Fiskus W, Chen J, Wei P, Schlette E, Xu J, Li S, Kanagal-Shamanna R, Yang H, Tang Z, Thakral B, Loghavi S, Jain N, Thompson PA, Ferrajoli A, Wierda WG, Jabbour E, Patel KP, Dabaja BS, Bhalla KN, Khoury JD. Immunophenotypic and genomic landscape of Richter transformation diffuse large B-cell lymphoma. Pathology 2023; 55:514-524. [PMID: 36933995 DOI: 10.1016/j.pathol.2022.12.354] [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: 09/17/2022] [Revised: 12/04/2022] [Accepted: 12/14/2022] [Indexed: 02/27/2023]
Abstract
Integrated clinicopathological and molecular analyses of Richter transformation of diffuse large B-cell lymphoma subtype (RT-DLBCL) cases remain limited. This study group included 142 patients with RT-DLBCL. Morphological evaluation and immunophenotyping, using immunohistochemistry and/or multicolour flow cytometry, were performed. The results of conventional karyotyping, fluorescence in situ hybridisation analysis and mutation profiling performed using next generation sequencing were reviewed. Patients included 91 (64.1%) men and 51 (35.9%) women with a median age of 65.4 years (range 25.4-84.9 years) at the time of RT-DLBCL diagnosis. Patients had CLL for a median of 49.5 months (range 0-330 months) before onset of RT-DLBCL. Most cases (97.2%) of RT-DLBCL had immunoblastic (IB) morphology, the remainder had a high grade morphology. The most commonly expressed markers included: CD19 (100%), PAX5 (100%), BCL2 (97.5%), LEF1 (94.7%), CD22 (90.2%), CD5 (88.6%), CD20 (85.7%), CD38 (83.5%), MUM1 (83.3%), CD23 (77%) and MYC (46.3%). Most (51/65, 78.4%) cases had a non-germinal centre B-cell immunophenotype. MYC rearrangement was detected in 9/47 (19.1%) cases, BCL2 rearrangement was detected in 5/22 (22.7%) cases, and BCL6 rearrangement was detected in 2/15 (13.3%) cases. In comparison to CLL, RT-DLBCL had higher numbers of alterations involving chromosomes 6, 17, 21, and 22. The most common mutations detected in RT-DLBCL involved TP53 (9/14, 64.3%), NOTCH1 (4/14, 28.6%) and ATM (3/14, 21.4%). Among RT-DLBCL cases with mutant TP53, 5/8 (62.5%) had TP53 copy number loss, and among those, such loss was detected in the CLL phase of the disease in 4/8 (50%) cases. There was no significant difference in overall survival (OS) between patients with germinal centre B-cell (GCB) and non-GCB RT-DLBCL. Only CD5 expression correlated significantly with OS (HR=2.732; 95% CI 1.397-5.345; p=0.0374). RT-DLBCL has distinctive morphological and immunophenotypic features, characterised by IB morphology and common expression of CD5, MUM1 and LEF1. Cell-of-origin does not seem to have prognostic implications in RT-DLBCL.
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Affiliation(s)
- Siba El Hussein
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pathology, University of Rochester Medical Center, Rochester, NY, USA.
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kirill A Lyapichev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pathology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hong Fang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fatima Zahra Jelloul
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Warren Fiskus
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jiansong Chen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peng Wei
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ellen Schlette
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jie Xu
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shaoying Li
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hong Yang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhenya Tang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Beenu Thakral
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, 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
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kapil N Bhalla
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pathology, The University of Nebraska Medical Center, Omaha, NE, USA.
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20
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Immunological Aspects of Richter Syndrome: From Immune Dysfunction to Immunotherapy. Cancers (Basel) 2023; 15:cancers15041015. [PMID: 36831361 PMCID: PMC9954516 DOI: 10.3390/cancers15041015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/19/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Richter Syndrome (RS) is defined as the development of an aggressive lymphoma in patients with a previous or simultaneous diagnosis of chronic lymphocytic leukemia (CLL). Two pathological variants of RS are recognized: diffuse large B-cell lymphoma (DLBCL)-type and Hodgkin lymphoma (HL)-type RS. Different molecular mechanisms may explain the pathogenesis of DLBCL-type RS, including genetic lesions, modifications of immune regulators, and B cell receptor (BCR) pathway hyperactivation. Limited data are available for HL-type RS, and its development has been reported to be similar to de novo HL. In this review, we focus on the immune-related pathogenesis and immune system dysfunction of RS, which are linked to BCR over-reactivity, altered function of the immune system due to the underlying CLL, and specific features of the RS tumor microenvironment. The standard of care of this disease consists in chemoimmunotherapy, eventually followed by stem cell transplantation, but limited possibilities are offered to chemo-resistant patients, who represent the majority of RS cases. In order to address this unmet clinical need, several immunotherapeutic approaches have been developed, namely T cell engagement obtained with bispecific antibodies, PD-1/PD-L1 immune checkpoint blockade by the use of monoclonal antibodies, selective drug delivery with antibody-drug conjugates, and targeting malignant cells with anti-CD19 chimeric antigen receptor-T cells.
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21
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Smyth E, Eyre TA, Cheah CY. Emerging Therapies for the Management of Richter Transformation. J Clin Oncol 2023; 41:395-409. [PMID: 36130148 DOI: 10.1200/jco.22.01028] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Richter transformation (RT) refers to the development of an aggressive lymphoma in patients with underlying chronic lymphocytic leukemia/small lymphocytic lymphoma. Aside from a small subgroup of patients with clonally unrelated and previously untreated chronic lymphocytic leukemia, the disease responds poorly to standard therapies and prognosis is dismal. Recent developments in the understanding of the biology of RT and the advent of several targeted agents may result in improved outcomes for these patients. The purpose of this review is to analyze recent data on the pathogenesis and treatment of RT. We reviewed studies addressing the pathophysiology of RT and analyzed the data for frontline chemoimmunotherapy and emerging targeted therapies likely to play a significant role in the future management of RT. Several biologic and clinical factors may help identify those who are unlikely to respond to conventional chemoimmunotherapy; where possible, these patients should be managed with a novel approach. Emerging therapies for the management of RT include chimeric antigen receptor T-cell therapy, noncovalent Bruton tyrosine kinase inhibitors, and T-cell-engaging bispecific antibodies. The use of less toxic and more effective targeted therapies may result in improved outcomes. Larger, prospective clinical trials are required to confirm efficacy and safety of novel agents for the management of RT, particularly when used in combination with other targeted therapies and in addition to chemoimmunotherapy regimens.
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Affiliation(s)
- Elizabeth Smyth
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Toby A Eyre
- Haematology and Cancer Centre, Oxford University Hospitals NHS Foundation Trust Oxford, Oxford, United Kingdom
| | - Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
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22
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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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23
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Behdad A, Schipma MJ, Ma S, Chen YH, Chen QC. Distinct immune-response profile of Richter transformation chronic lymphocytic leukemia (CLL), defined by high expression of PD1, LAG3, TIM3 and IL-10. Leuk Lymphoma 2022; 63:3222-3226. [PMID: 36102789 DOI: 10.1080/10428194.2022.2123236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Amir Behdad
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Medicine (Hematology and Oncology), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Matthew John Schipma
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shuo Ma
- Department of Medicine (Hematology and Oncology), Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yi-Hua Chen
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Qing Ching Chen
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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24
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Sha YQ, Jiang R, Miao Y, Qiu TL, Qin SC, Qiu JY, Mi HL, Wu W, Qiao C, Wu YJ, Xia Y, Wang L, Fan L, Xu W, Li JY, Zhu HY. [Clonality relatedness and molecular characteristics of Richter transformation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:841-847. [PMID: 36709198 PMCID: PMC9669627 DOI: 10.3760/cma.j.issn.0253-2727.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Indexed: 11/23/2022]
Abstract
Objective: To investigate the clinical, genetic, and clonality related aspects of individuals with Richter transformation (RT) . Methods: From January 2019 to December 2021, 18 RT patients with diagnoses at the First Affiliated Hospital of Nanjing Medical University (Pukou CLL center) were retrospectively examined. The immunoglobin heavy variable (IGHV) gene usage and IGHV-D-J rearrangement pattern of diagnosed CLL/SLL and transformed diffuse large B-cell lymphoma (DLBCL) were compared to determine the clonality relatedness. To investigate the risk factors of RT, Clinical and laboratory data from patients with newly diagnosed CLL/SLL and transformed DLBCL were gathered. Results: The median age of RT was 56.5 (41-75) years old. 17 patients transformed to DLBCL and 1 transformed to Hodgkin lymphoma (HL) . Of 17 individuals who had DLBCL transformation, 15 had CLL/SLL-related clonality and 2 had unrelated clonality. Next-generation sequencing (NGS) analysis of 11 paired initially diagnosed treatment-naive CLL/SLL and RT DLBCL found that EGR2、TP53 and NOTCH1 were among the most frequently mutated genes both in treatment-naive CLL/SLL and in RT DLBCL. In several cases, specific mutations were gained or lost throughout RT, indicating clonal evolution. Among 10 patients before exposure to BTK inhibitors before RT, four patients acquired BTK mutation. The aforementioned mutations should be considered high-risk variables for transformation; in addition, TP53 and EGR2 mutations could be linked to a poor prognosis following RT in patients receiving a cocktail of new medicines. Conclusion: Most RT DLBCL patients in our center are clonality related (15/17, 88.2% ) and we recommend all qualified centers to evaluate clonality relatedness of RT DLBCL patients. There was some variability in the mutational landscape between DLBCL that had undergone a transformation and initially diagnosed, treatment-naive CLL/SLL. The underlying molecular mechanism of RT needs more research.
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Affiliation(s)
- Y Q Sha
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - R Jiang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Y Miao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - T L Qiu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - S C Qin
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - J Y Qiu
- Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
| | - H L Mi
- Pukou CLL Center, Pukou Division of Jiangsu Province Hospital, Nanjing 211800, China
| | - W Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - C Qiao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Y J Wu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - Y Xia
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - L Wang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - L Fan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - W Xu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - J Y Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
| | - H Y Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing 210029, China
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25
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Richter Syndrome: From Molecular Pathogenesis to Druggable Targets. Cancers (Basel) 2022; 14:cancers14194644. [PMID: 36230566 PMCID: PMC9563287 DOI: 10.3390/cancers14194644] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
Richter syndrome (RS) represents the occurrence of an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL), in patients with chronic lymphocytic leukemia (CLL). Most cases of RS originate from the direct transformation of CLL, whereas 20% are de novo DLBCL arising as secondary malignancies. Multiple molecular mechanisms contribute to RS pathogenesis. B-cell receptor (BCR) overreactivity to multiple autoantigens is due to frequent stereotyped BCR configuration. Genetic lesions of TP53, CDKN2A, NOTCH1 and c-MYC deregulate DNA damage response, tumor suppression, apoptosis, cell cycle and proliferation. Hyperactivation of Akt and NOTCH1 signaling also plays a role. Altered expression of PD-1/PD-L1 and of other immune checkpoints leads to RS resistance to cytotoxicity exerted by T-cells. The molecular features of RS provide vulnerabilities for therapy. Targeting BCR signaling with noncovalent BTK inhibitors shows encouraging results, as does the combination of BCL2 inhibitors with chemoimmunotherapy. The association of immune checkpoint inhibitors with BCL2 inhibitors and anti-CD20 monoclonal antibodies is explored in early phase clinical trials with promising results. The development of patient-derived xenograft mice models reveals new molecular targets for RS, exemplified by ROR1. Although RS still represents an unmet medical need, understanding its biology is opening new avenues for precision medicine therapy.
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26
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Symes E, Wang P, Lager AM, Bishop MR, Aqil B, Venkataraman G. TP53/PLCG2-mutated diffuse large B-cell lymphoma richter transformation (DLBCL-RT) of CLL with unusual CD2 and PD-1 expression. Leuk Lymphoma 2022; 63:2735-2738. [DOI: 10.1080/10428194.2022.2087070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Emily Symes
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Peng Wang
- Department of Pathology, University of Chicago, Chicago, IL, USA
| | - Angela M. Lager
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael R. Bishop
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, IL, USA
| | - Barina Aqil
- Division of Hematopathology, Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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27
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Condoluci A, Rossi D. Biology and Treatment of Richter Transformation. Front Oncol 2022; 12:829983. [PMID: 35392219 PMCID: PMC8980468 DOI: 10.3389/fonc.2022.829983] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/25/2022] [Indexed: 12/28/2022] Open
Abstract
Richter transformation (RT), defined as the development of an aggressive lymphoma on a background of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), represents a clinical unmet need because of its dismal prognosis. An increasing body of knowledge in the field of RT is arising from the recent development of preclinical models depicting the biology underlying this aggressive disease. Consistently, new therapeutic strategies based on a genetic rationale are exploring actionable pathogenic pathways to improve the outcome of patients in this setting. In this review, we summarize the current understandings on RT biology and the available treatment options.
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Affiliation(s)
- Adalgisa Condoluci
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
| | - Davide Rossi
- Division of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Laboratory of Experimental Hematology, Institute of Oncology Research, Bellinzona, Switzerland.,Università della Svizzera Italiana, Lugano, Switzerland
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28
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Abstract
PURPOSE OF REVIEW Richter's transformation (RT) occurs when chronic (CLL) transforms into an aggressive lymphoma. Despite improvements in the treatment of CLL, prognosis for RT remains poor. Here, we review current literature of RT, with a focus on novel treatment options. RECENT FINDINGS Efforts are underway to improve outcomes for patients with RT. While small molecule inhibitors have limited efficacy as monotherapy, recent developments combining them with chemo-immunotherapy show promise. Studies exploring the use of cellular therapies including chimeric antigen receptor T-cells and bispecific antibodies are ongoing. The current treatment paradigm for RT is to enroll these patients on a clinical trial when available, together with consultation for a consolidative allogeneic stem cell transplant. Trials investigating novel combinations and cellular therapy are ongoing. Determining predictive variables of transformation is imperative to design studies that allow for early identification and intervention for patients with RT.
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Affiliation(s)
- Audrey M Sigmund
- Division of Hematology, Department of Internal Medicine, The Ohio State University, 11th Floor Lincoln Tower and 1140D Lincoln Tower, 1800 Cannon Drive, Columbus, OH, 43210, USA
| | - Adam S Kittai
- Division of Hematology, Department of Internal Medicine, The Ohio State University, 11th Floor Lincoln Tower and 1140D Lincoln Tower, 1800 Cannon Drive, Columbus, OH, 43210, USA.
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29
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Iannello A, Deaglio S, Vaisitti T. Novel Approaches for the Treatment of Patients with Richter's Syndrome. Curr Treat Options Oncol 2022; 23:526-542. [PMID: 35294723 PMCID: PMC8989931 DOI: 10.1007/s11864-022-00973-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 12/19/2022]
Abstract
In the last 10–15 years, the way to treat cancers has dramatically changed towards precision medicine approaches. These treatment options are mainly based on selective targeting against signaling pathways critical for or detrimentally activated in cancer cells in cancer cells, as well as exploiting molecules that are specifically expressed on neoplastic cells, also known as tumor-associated antigens. These considerations hold true also in the hematological field where a plethora of novel targeted agents have reached patients’ bedside, significantly improving clinical responses. Chronic lymphocytic leukemia (CLL) is an example of how targeted therapies, such as BTK, PI3K, or Bcl-2 inhibitors as well as anti-CD20 antibodies, have improved patients’ management, even when adopted as frontline treatment. However, these advancements do not apply to Richter’s syndrome (RS), the transformation of CLL into a very aggressive and fatal lymphoma, occurring in 2–10% of patients. RS is usually a fast-growing lymphoma of the diffuse large B cell or the Hodgkin’s variant, with a dismal prognosis. Despite advancements in depicting and understanding the genetic background of RS and its pathogenesis, no significant clinical results have been registered. In the last couple of years, several studies have started to investigate the impact of novel drugs or drug combinations and some of them have opened for clinical trials, currently in phase I or II, whose results will be soon available. This review will present an overview of current and most recent therapeutic options in RS, discussing also how results coming from xenograft models may help in designing and identifying novel treatment opportunities to overcome the lack of effective therapies.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Prognosis
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Affiliation(s)
- Andrea Iannello
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
| | - Silvia Deaglio
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
| | - Tiziana Vaisitti
- Functional Genomics Unit, Department of Medical Sciences, University of Torino, Via Nizza 52, 10126 Turin, Italy
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30
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Doytcheva K, Lager A, Venkataraman G. De novo PD-1-expressing large B-cell lymphoma outside the setting of CLL: possible origin from CD5 + /PD-1 + regulatory B-cell subset. J Hematop 2021. [DOI: 10.1007/s12308-021-00474-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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31
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Garcia-Lacarte M, Grijalba SC, Melchor J, Arnaiz-Leché A, Roa S. The PD-1/PD-L1 Checkpoint in Normal Germinal Centers and Diffuse Large B-Cell Lymphomas. Cancers (Basel) 2021; 13:4683. [PMID: 34572910 PMCID: PMC8471895 DOI: 10.3390/cancers13184683] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/13/2021] [Indexed: 12/20/2022] Open
Abstract
Besides a recognized role of PD-1/PD-L1 checkpoint in anti-tumour immune evasion, there is accumulating evidence that PD-1/PD-L1 interactions between B and T cells also play an important role in normal germinal center (GC) reactions. Even when smaller in number, T follicular helper cells (TFH) and regulatory T (TFR) or B (Breg) cells are involved in positive selection of GC B cells and may result critical in the lymphoma microenvironment. Here, we discuss a role of PD-1/PD-L1 during tumour evolution in diffuse large B cell lymphoma (DLBCL), a paradigm of GC-derived lymphomagenesis. We depict a progression model, in two phases, where malignant B cells take advantage of positive selection signals derived from correct antigen-presentation and PD-1/PD-L1 inter-cellular crosstalks to survive and initiate tumour expansion. Later, a constant pressure for the accumulation of genetic/epigenetic alterations facilitates that DLBCL cells exhibit higher PD-L1 levels and capacity to secrete IL-10, resembling Breg-like features. As a result, a complex immunosuppressive microenvironment is established where DLBCL cells sustain proliferation and survival by impairing regulatory control of TFR cells and limiting IL-21-mediated anti-tumour functions of TFH cells and maximize the use of PD-1/PD-L1 signaling to escape from CD8+ cytotoxic activity. Integration of these molecular and cellular addictions into a framework may contribute to the better understanding of the lymphoma microenvironment and contribute to the rationale for novel PD-1/PD-L1-based combinational immunotherapies in DLBCL.
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Affiliation(s)
- Marcos Garcia-Lacarte
- Department of Biochemistry and Genetics, University of Navarra, 31008 Pamplona, Spain; (M.G.-L.); (S.C.G.); (J.M.); (A.A.-L.)
- Hemato-Oncology Program, Cima University of Navarra, 31008 Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
| | - Sara C. Grijalba
- Department of Biochemistry and Genetics, University of Navarra, 31008 Pamplona, Spain; (M.G.-L.); (S.C.G.); (J.M.); (A.A.-L.)
| | - Javier Melchor
- Department of Biochemistry and Genetics, University of Navarra, 31008 Pamplona, Spain; (M.G.-L.); (S.C.G.); (J.M.); (A.A.-L.)
- Hemato-Oncology Program, Cima University of Navarra, 31008 Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
| | - Adrián Arnaiz-Leché
- Department of Biochemistry and Genetics, University of Navarra, 31008 Pamplona, Spain; (M.G.-L.); (S.C.G.); (J.M.); (A.A.-L.)
| | - Sergio Roa
- Department of Biochemistry and Genetics, University of Navarra, 31008 Pamplona, Spain; (M.G.-L.); (S.C.G.); (J.M.); (A.A.-L.)
- Hemato-Oncology Program, Cima University of Navarra, 31008 Pamplona, Spain
- Navarra Institute for Health Research (IdiSNA), 31008 Pamplona, Spain
- Network Center for Biomedical Research in Cancer—Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Institute of Health Carlos III, 28029 Madrid, Spain
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32
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Venetoclax-resistant CLL cells show a highly activated and proliferative phenotype. Cancer Immunol Immunother 2021; 71:979-987. [PMID: 34467417 DOI: 10.1007/s00262-021-03043-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/22/2021] [Indexed: 10/20/2022]
Abstract
Venetoclax treatment has demonstrated efficacy and a safety profile in chronic lymphocytic leukemia (CLL) patients, however the emergence of resistant cells is a current complication. We and others, previously reported that the activation of CLL cells by signals that mimic microenvironment stimuli favors the upregulation of anti-apoptotic proteins from B cell lymphoma-2 (BCL-2) family that are not targeted by venetoclax, reducing malignant cell sensitivity to the drug. We here studied venetoclax-resistant CLL cells generated in vitro by autologous activated T lymphocytes, and found that they showed an aggressive phenotype characterized by increased expression of activation and proliferation markers. Moreover, surviving cells expressed high levels of B cell lymphoma-extra-large (BCL-XL) and/or myeloid cell leukemia-1 (MCL-1), and a sustained resistance to a second treatment with the drug. Interestingly, the spleen tyrosine kinase (SYK) inhibitor entospletinib, and the phosphoinositide 3-kinase delta (PI3Kδ) inhibitor idelalisib, reduced T cell activation, impaired the generation of leukemic cells with this aggressive phenotype, and were able to restore CLL sensitivity to venetoclax. Our data highlight a novel combination to overcome resistance to venetoclax in CLL.
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Gould C, Lickiss J, Kankanige Y, Yerneni S, Lade S, Gandhi MK, Chin C, Yannakou CK, Villa D, Slack GW, Markham JF, Tam CS, Nelson N, Seymour JF, Dickinson M, Neeson PJ, Westerman D, Blombery P. Characterisation of immune checkpoints in Richter syndrome identifies LAG3 as a potential therapeutic target. Br J Haematol 2021; 195:113-118. [PMID: 34426978 DOI: 10.1111/bjh.17789] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/09/2021] [Accepted: 08/07/2021] [Indexed: 12/17/2022]
Abstract
Richter syndrome (RS), an aggressive lymphoma occurring in the context of chronic lymphocytic leukaemia/small lymphocytic lymphoma, is associated with poor prognosis when treated with conventional immunochemotherapy, therefore, improved treatments are required. Immune checkpoint blockade has shown efficacy in some B-cell malignancies and modest responses in early clinical trials for RS. We investigated the immune checkpoint profile of RS as a basis to inform rational therapeutic investigations in RS. Formalin-fixed, paraffin-embedded biopsies of RS (n = 19), de novo diffuse large B-cell lymphoma (DLBCL; n = 58), transformed indolent lymphomas (follicular [tFL], n = 16; marginal zone [tMZL], n = 24) and non-transformed small lymphocytic lymphoma (SLL; n = 15) underwent gene expression profiling using the NanoString Human Immunology panel. Copy number assessment was performed using next-generation sequencing. Immunohistochemistry (IHC) for LAG3 and PD-1 was performed. LAG3 gene expression was higher in RS compared to DLBCL (P = 0·0002, log2FC 1·96), tFL (P < 0·0001, log2FC 2·61), tMZL (P = 0·0004, log2FC 1·79) and SLL (P = 0·0057, log2FC 1·45). LAG3 gene expression correlated with the gene expression of human leukocyte antigen Class I and II, and related immune genes and immune checkpoints. IHC revealed LAG3 protein expression on both malignant RS cells and tumour-infiltrating lymphocytes. Our findings support the investigation of LAG3 inhibition to enhance anti-tumour responses in RS.
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Affiliation(s)
- Clare Gould
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Jennifer Lickiss
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Yamuna Kankanige
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Satwica Yerneni
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Stephen Lade
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Maher K Gandhi
- Mater Research, University of Queensland, Brisbane, Australia.,Haematology, Princess Alexandra Hospital, Brisbane, Australia
| | - Collin Chin
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | | | - Diego Villa
- Centre for Lymphoid Cancer and Division of Medical Oncology, BC Cancer, Vancouver, Canada
| | - Graham W Slack
- Centre for Lymphoid Cancer and Division of Medical Oncology, BC Cancer, Vancouver, Canada.,Centre for Lymphoid Cancer and Department of Pathology and Laboratory Medicine, BC Cancer, Vancouver, Canada
| | - John F Markham
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Constantine S Tam
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Niles Nelson
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - John F Seymour
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Dickinson
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Paul J Neeson
- University of Melbourne, Melbourne, Australia.,Cancer Immunology Program, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - David Westerman
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
| | - Piers Blombery
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Royal Melbourne Hospital, Melbourne, Australia
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34
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Ding W. The Ongoing Unmet Needs in Chronic Lymphocytic Leukemia: TP53 Disruption, Richter, and Beyond. Hematol Oncol Clin North Am 2021; 35:739-759. [PMID: 34174984 DOI: 10.1016/j.hoc.2021.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Despite recent success in regard to targeted therapies in chronic lymphocytic leukemia (CLL), patients with TP53 disruption (including deletion and/or mutation) continue to have poor outcomes compared with other patients with CLL. In this article, a review of common TP53 mutations in CLL, and recent trials using novel targeted agents in CLL patients with TP53 disruption, is provided with the goal of emphasizing the need to continuously focus on this area of research. In addition, limited but available data on double refractory CLL to BTK inhibitor and BCL-2 inhibitor, and on Richter syndrome, are reviewed.
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Affiliation(s)
- Wei Ding
- Division of Hematology, Mayo Clinic, 200 First Street, Southwest, Rochester, MN 55905, USA.
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35
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Incidental Richter transformation in chronic lymphocytic leukemia patients during temporary interruption of ibrutinib. Blood Adv 2021; 4:4508-4511. [PMID: 32946567 DOI: 10.1182/bloodadvances.2020002454] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/14/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
An incidental histologic diagnosis of DLBCL was identified during temporary interruption of ibrutinib treatment in patients with CLL. In contrast to an aggressive clinical course typical of Richter transformation, these patients responded to reinitiation of ibrutinib alone.
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36
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Distinct immune signatures in chronic lymphocytic leukemia and Richter syndrome. Blood Cancer J 2021; 11:86. [PMID: 33972504 PMCID: PMC8110984 DOI: 10.1038/s41408-021-00477-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/28/2021] [Accepted: 04/13/2021] [Indexed: 12/24/2022] Open
Abstract
Richter syndrome (RS) refers to transformation of chronic lymphocytic leukemia (CLL) to an aggressive lymphoma, most commonly diffuse large B-cell lymphoma. RS is known to be associated with a number of genetic alterations such as TP53 and NOTCH1 mutations. However, it is unclear what immune microenvironment changes are associated with RS. In this study, we analyzed expression of immune checkpoint molecules and infiltration of immune cells in nodal samples, and peripheral blood T-cell diversity in 33 CLL and 37 RS patients. Compared to CLL, RS nodal tissue had higher PD-L1 expression in histiocytes and dendritic cells (median 16.6% vs. 2.8%, P < 0.01) and PD1 expression in neoplastic B cells (median 26.0% vs. 6.2%, P < 0.01), and higher infiltration of FOXP3-positive T cells (median 1.7% vs. 0.4%, P < 0.01) and CD163-positive macrophages (median 23.4% vs. 9.1%, P < 0.01). In addition, peripheral blood T-cell receptor clonality was significantly lower in RS vs. CLL patients (median [25th–75th], 0.107 [0.070–0.209] vs. 0.233 [0.111–0.406], P = 0.046), suggesting that T cells in RS patients were significantly more diverse than in CLL patients. Collectively these data suggest that CLL and RS have distinct immune signatures. Better understanding of the immune microenvironment is essential to improve immunotherapy efficacy in CLL and RS.
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37
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Petrackova A, Turcsanyi P, Papajik T, Kriegova E. Revisiting Richter transformation in the era of novel CLL agents. Blood Rev 2021; 49:100824. [PMID: 33775465 DOI: 10.1016/j.blre.2021.100824] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/14/2021] [Accepted: 02/19/2021] [Indexed: 12/18/2022]
Abstract
Richter transformation (RT) is the development of aggressive lymphoma - most frequently diffuse large B-cell lymphoma (DLBCL) and rarely Hodgkin lymphoma (HL) - arising on the background of chronic lymphocytic leukaemia (CLL). Despite recent advances in CLL treatment, RT also develops in patients on novel agents, usually occurring as an early event. RT incidence is lower in CLL patients treated with novel agents in the front line compared to relapsed/refractory cases, with a higher incidence in patients with TP53 disruption. The genetic heterogeneity and complexity are higher in RT-DLBCL than CLL; the genetics of RT-HL are largely unknown. In addition to TP53, aberrations in CDKN2A, MYC, and NOTCH1 are common in RT-DLBCL; however, no distinct RT-specific genetic aberration is recognised yet. RT-DLBCL on ibrutinib is frequently associated with BTK and PLCG2 mutations. Here, we update on genetic analysis, diagnostics and treatment options in RT in the era of novel agents.
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Affiliation(s)
- Anna Petrackova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Peter Turcsanyi
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Tomas Papajik
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Eva Kriegova
- Department of Immunology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, Olomouc, Czech Republic.
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38
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Lu S, Zhao S. EBV-positive diffuse large B-cell lymphoma, not otherwise specified masking Richter syndrome. Int J Hematol 2021; 113:613-615. [PMID: 33594655 DOI: 10.1007/s12185-021-03098-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/28/2021] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Susu Lu
- Department of Pathology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan, China
| | - Sha Zhao
- Department of Pathology, West China Hospital, Sichuan University, No. 37 GuoXue Xiang, Chengdu, 610041, Sichuan, China.
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39
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40
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Schmid T, Maier J, Martin M, Tasdogan A, Tausch E, Barth TFE, Stilgenbauer S, Bloehdorn J, Möller P, Mellert K. U-RT1 - A new model for Richter transformation. Neoplasia 2021; 23:140-148. [PMID: 33316538 PMCID: PMC7736907 DOI: 10.1016/j.neo.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/25/2022]
Abstract
The advent of highly effective treatments targeting the disease biology of chronic lymphocytic leukemia (CLL) has transformed the therapeutic field tremendously. However, transformation into an aggressive B-cell lymphoma, called Richter syndrome (RS), remains highly challenging since the treatment options for this condition are still insufficient. Exploratory drug testing and experimental studies are restricted by the lack of satisfactory models. We have established U-RT1, a cell line derived from a highly proliferating RS clonally related to the patient's underlying CLL. The cell line shows morphological features and an immunophenotype of RS-DLBCL (non-GCB). Molecular analysis revealed a complex karyotype with driver aberrations characteristic for RS such as loss of TP53 and CDKN2A. Furthermore, U-RT1 displays a chromosomal gain of the NOTCH1 gene locus and strong immunoreactivity for BCL-2. These features suggest that U-RT1 is the first eligible model system for investigations on the pathogenesis of RS and novel treatment options.
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MESH Headings
- Apoptosis/genetics
- Biomarkers
- Biomarkers, Tumor
- Cell Line, Tumor
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/metabolism
- Comparative Genomic Hybridization
- Disease Progression
- Humans
- Immunohistochemistry
- In Situ Hybridization, Fluorescence
- Karyotype
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Middle Aged
- Mutation
- Primary Cell Culture
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Affiliation(s)
- Teresa Schmid
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
| | - Julia Maier
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
| | - Melanie Martin
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
| | | | - Eugen Tausch
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | | | | | - Johannes Bloehdorn
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Peter Möller
- Institute of Pathology, University Hospital Ulm, Ulm, Germany.
| | - Kevin Mellert
- Institute of Pathology, University Hospital Ulm, Ulm, Germany
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41
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Augé H, Notarantonio AB, Morizot R, Quinquenel A, Fornecker LM, Hergalant S, Feugier P, Broséus J. Microenvironment Remodeling and Subsequent Clinical Implications in Diffuse Large B-Cell Histologic Variant of Richter Syndrome. Front Immunol 2020; 11:594841. [PMID: 33381116 PMCID: PMC7767850 DOI: 10.3389/fimmu.2020.594841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Richter Syndrome (RS) is defined as the development of an aggressive lymphoma in the context of Chronic Lymphocytic Leukemia (CLL), with a Diffuse Large B-Cell Lymphoma (DLBCL) histology in 95% cases. RS genomic landscape shares only a few features with de novo DLBCLs and is marked by a wide spectrum of cytogenetic abnormalities. Little is known about RS microenvironment. Therapeutic options and efficacy are limited, leading to a 12 months median overall survival. The new targeted treatments usually effective in CLL fail to obtain long-term remissions in RS. Methods We reviewed available PubMed literature about RS genomics, PD-1/PD-L1 (Programmed Death 1/Programmed Death Ligand 1) pathway triggering and subsequent new therapeutic options. Results Data from about 207 patients from four landmark papers were compiled to build an overview of RS genomic lesions and point mutations. A number of these abnormalities may be involved in tumor microenvironment reshaping. T lymphocyte exhaustion through PD-L1 overexpression by tumor cells and subsequent PD-1/PD-L1 pathway triggering is frequently reported in solid cancers. This immune checkpoint inhibitor is also described in B lymphoid malignancies, particularly CLL: PD-1 expression is reported in a subset of prolymphocytes from the CLL lymph node proliferation centers. However, there is only few data about PD-1/PD-L1 pathway in RS. In RS, PD-1 expression is a hallmark of recently described « Regulatory B-cells », which interact with tumor microenvironment by producing inhibiting cytokines such as TGF-β and IL-10, impairing T lymphocytes anti-tumoral function. Based upon the discovery of high PD-1 expression on tumoral B lymphocyte from RS, immune checkpoint blockade therapies such as anti-PD-1 antibodies have been tested on small RS cohorts and provided heterogeneous but encouraging results. Conclusion RS genetic landscape and immune evasion mechanisms are being progressively unraveled. New protocols using targeted treatments such as checkpoint inhibitors as single agents or in combination with immunochemotherapy are currently being evaluated.
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Affiliation(s)
- Hélène Augé
- Inserm UMRS1256 Nutrition-Génétique et Exposition aux Risque Environnementaux (N-GERE), Université de Lorraine, Nancy, France.,Université de Lorraine, CHRU-Nancy, service d'hématologie clinique, pôle spécialités médicales, Nancy, France
| | - Anne-Béatrice Notarantonio
- Université de Lorraine, CHRU-Nancy, service d'hématologie clinique, pôle spécialités médicales, Nancy, France.,UMR7365 Ingénierie Moléculaire et Physiopathologie Articulaire (IMOPA), CNRS, Université de Lorraine, Nancy, France
| | - Romain Morizot
- Inserm UMRS1256 Nutrition-Génétique et Exposition aux Risque Environnementaux (N-GERE), Université de Lorraine, Nancy, France.,Université de Lorraine, CHRU-Nancy, service d'hématologie clinique, pôle spécialités médicales, Nancy, France
| | - Anne Quinquenel
- Département d'hématologie, Université de Reims Champagne-Ardenne, Reims, France.,Département d'hématologie clinique, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Luc-Matthieu Fornecker
- Université de Strasbourg, Inserm, IRFAC/UMR-S1113, Strasbourg, France.,Département d'hématologie clinique, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | - Sébastien Hergalant
- Inserm UMRS1256 Nutrition-Génétique et Exposition aux Risque Environnementaux (N-GERE), Université de Lorraine, Nancy, France
| | - Pierre Feugier
- Inserm UMRS1256 Nutrition-Génétique et Exposition aux Risque Environnementaux (N-GERE), Université de Lorraine, Nancy, France.,Université de Lorraine, CHRU-Nancy, service d'hématologie clinique, pôle spécialités médicales, Nancy, France
| | - Julien Broséus
- Inserm UMRS1256 Nutrition-Génétique et Exposition aux Risque Environnementaux (N-GERE), Université de Lorraine, Nancy, France.,Université de Lorraine, CHRU-Nancy, service d'hématologie biologique, pôle laboratoires, Nancy, France
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42
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Activating the Antitumor Immune Response in Non-Hodgkin Lymphoma Using Immune Checkpoint Inhibitors. J Immunol Res 2020; 2020:8820377. [PMID: 33294467 PMCID: PMC7690999 DOI: 10.1155/2020/8820377] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/29/2020] [Indexed: 12/31/2022] Open
Abstract
Non-Hodgkin lymphomas comprise a heterogenous group of disorders which differ in biology. Although response rates are high in some groups, relapsed disease can be difficult to treat, and newer approaches are needed for this patient population. It is increasingly apparent that the immune system plays a significant role in the propagation and survival of malignant cells. Immune checkpoint blocking agents augment cytotoxic activity of the adaptive and innate immune systems and enhance tumor cell killing. Anti-PD-1 and anti-CTLA-4 antibodies have been tested as both single agents and combination therapy. Although success rates with anti-PD-1 antibodies are high in patients with Hodgkin lymphoma, the results are yet to be replicated in those with non-Hodgkin lymphomas. Some lymphoma histologies, such as primary mediastinal B cell lymphoma (PMBL), central nervous system, and testicular lymphomas and gray zone lymphoma, respond favorably to PD-1 blockade, but the response rates in most lymphoma subtypes are low. Other agents including those targeting the adaptive immune system such as TIM-3, TIGIT, and BTLA and innate immune system such as CD47 and KIR are therefore in trials to test alternative ways to activate the immune system. Patient selection based on tumor biology is likely to be a determining factor in treatment response in patients, and further research exploring optimal patient populations, newer targets, and combination therapy as well as identifying biomarkers is needed.
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43
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Current Clinical Applications and Future Perspectives of Immune Checkpoint Inhibitors in Non-Hodgkin Lymphoma. J Immunol Res 2020; 2020:9350272. [PMID: 33178841 PMCID: PMC7647776 DOI: 10.1155/2020/9350272] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/10/2020] [Accepted: 09/17/2020] [Indexed: 12/17/2022] Open
Abstract
Cancer cells escape immune recognition by exploiting the programmed cell-death protein 1 (PD-1)/programmed cell-death 1 ligand 1 (PD-L1) immune checkpoint axis. Immune checkpoint inhibitors that target PD-1/PD-L1 unleash the properties of effector T cells that are licensed to kill cancer cells. Immune checkpoint blockade has dramatically changed the treatment landscape of many cancers. Following the cancer paradigm, preliminary results of clinical trials in lymphoma have demonstrated that immune checkpoint inhibitors induce remarkable responses in specific subtypes, most notably classical Hodgkin lymphoma and primary mediastinal B-cell lymphoma, while in other subtypes, the results vary considerably, from promising to disappointing. Lymphomas that respond to immune checkpoint inhibitors tend to exhibit tumor cells that reside in a T-cell-rich immune microenvironment and display constitutive transcriptional upregulation of genes that facilitate innate immune resistance, such as structural variations of the PD-L1 locus, collectively referred to as T-cell-inflamed lymphomas, while those lacking such characteristics are referred to as noninflamed lymphomas. This distinction is not necessarily a sine qua non of response to immune checkpoint inhibitors, but rather a framework to move the field forward with a more rational approach. In this article, we provide insights on our current understanding of the biological mechanisms of immune checkpoint evasion in specific subtypes of B-cell and T-cell non-Hodgkin lymphomas and summarize the clinical experience of using inhibitors that target immune checkpoints in these subtypes. We also discuss the phenomenon of hyperprogression in T-cell lymphomas, related to the use of such inhibitors when T cells themselves are the target cells, and consider future approaches to refine clinical trials with immune checkpoint inhibitors in non-Hodgkin lymphomas.
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44
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Hasan S. An Overview of Promising Biomarkers in Cancer Screening and Detection. Curr Cancer Drug Targets 2020; 20:831-852. [PMID: 32838718 DOI: 10.2174/1568009620666200824102418] [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: 05/13/2020] [Revised: 07/03/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022]
Abstract
Applications of biomarkers have been proved in oncology screening, diagnosis, predicting response to treatment as well as monitoring the progress of the disease. Considering the crucial role played by them during different disease stages, it is extremely important to evaluate, validate, and assess them to incorporate them into routine clinical care. In this review, the role of few most promising and successfully used biomarkers in cancer detection, i.e. PD-L1, E-Cadherin, TP53, Exosomes, cfDNA, EGFR, mTOR with regard to their structure, mode of action, and reports signifying their pathological significance, are addressed. Also, an overview of some successfully used biomarkers for cancer medicine has been presented. The study also summarizes biomarker-driven personalized cancer therapy i.e., approved targets and indications, as per the US FDA. The review also highlights the increasingly prominent role of biomarkers in drug development at all stages, with particular reference to clinical trials. The increasing utility of biomarkers in clinical trials is clearly evident from the trend shown, wherein ~55 percent of all oncology clinical trials in 2019 were seen to involve biomarkers, as opposed to ~ 15 percent in 2001, which clearly proves the essence and applicability of biomarkers for synergizing clinical information with tumor progression. Still, there are significant challenges in the implementation of these possibilities with strong evidence in cost-- effective manner.
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Affiliation(s)
- Saba Hasan
- Amity Institute of Biotechnology, Amity University, Uttar Pradesh, Lucknow, India
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45
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Landego I, Hewitt D, Hibbert I, Dhaliwal D, Pieterse W, Grenier D, Wong R, Johnston J, Banerji V. PD-1 inhibition in malignant melanoma and lack of clinical response in chronic lymphocytic leukemia in the same patients: a case series. ACTA ACUST UNITED AC 2020; 27:169-172. [PMID: 32669928 DOI: 10.3747/co.27.5371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chronic lymphocytic leukemia (cll) is the most common adult leukemia in the Western world. Unfortunately, affected patients are often immunosuppressed and at increased risk of infection and secondary malignancy. Previous meta-analysis has found that patients with cll have a risk of melanoma that is increased by a factor of 4 compared with the general population. Recent advances in the understanding of the PD receptor pathway have led to immunotherapies that target cancer cells. The use of PD-1 inhibitors is now considered first-line treatment for BRAF wild-type metastatic melanoma. Interestingly, early preclinical data suggest that inhibition of that pathway could also be used in the treatment of cll; however, recent clinical data did not support the effectiveness of that approach. In this case series, we highlight 2 cases in which patients with cll and concurrent malignant melanoma underwent treatment with PD-1 inhibitors and were found to experience reductions in their white blood cell counts without improvement in their hemoglobin. Those cases further illustrate that treatment of cll with PD-1 inhibitors is ineffective.
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Affiliation(s)
- I Landego
- Department of Internal Medicine, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
| | - D Hewitt
- Research Institute of Oncology and Hematology, CancerCare Manitoba and the University of Manitoba, Winnipeg, MB
| | - I Hibbert
- Department of Nursing, CancerCare Manitoba, Winnipeg, MB
| | - D Dhaliwal
- Section of Hematology and Oncology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
| | - W Pieterse
- Russell Health Centre, Community Oncology Program, Winnipeg, MB
| | - D Grenier
- Section of Hematology and Oncology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
| | - R Wong
- Section of Hematology and Oncology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
| | - J Johnston
- Research Institute of Oncology and Hematology, CancerCare Manitoba and the University of Manitoba, Winnipeg, MB.,Section of Hematology and Oncology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
| | - V Banerji
- Research Institute of Oncology and Hematology, CancerCare Manitoba and the University of Manitoba, Winnipeg, MB.,Section of Hematology and Oncology, Rady College of Medicine, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB
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46
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Richter transformation in chronic lymphocytic leukemia (CLL)-a pooled analysis of German CLL Study Group (GCLLSG) front line treatment trials. Leukemia 2020; 35:169-176. [PMID: 32203141 DOI: 10.1038/s41375-020-0797-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/15/2020] [Accepted: 03/05/2020] [Indexed: 01/02/2023]
Abstract
Richter transformation (RT) is defined as development of aggressive lymphoma in patients (pts) with CLL. The incidence rates of RT among pts with CLL range from 2 to 10%. The aim of this analysis is to report the frequency, characteristics and outcomes of pts with RT enrolled in trials of the GCLLSG. A total of 2975 pts with advanced CLL were reviewed for incidence of RT. Clinical, laboratory, and genetic data were pooled. Time-to-event data, starting from time of CLL diagnosis, of first-line therapy or of RT diagnosis, were analyzed by Kaplan-Meier methodology. One hundred and three pts developed RT (3%): 95 pts diffuse large B-cell lymphoma (92%) and eight pts Hodgkin lymphoma (8%). Median observation time was 53 months (interquartile range 38.1-69.5). Median OS from initial CLL diagnosis for pts without RT was 167 months vs 71 months for pts with RT (HR 2.64, CI 2.09-3.33). Median OS after diagnosis of RT was 9 months. Forty-seven pts (46%) received CHOP-like regimens for RT treatment. Three pts subsequently underwent allogeneic and two pts autologous stem cell transplantation. Our findings show that within a large cohort of GCLLSG trial participants, 3% of the pts developed RT after receiving first-line chemo- or chemoimmunotherapy. This dataset confirms the ongoing poor prognosis and high mortality associated with RT.
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47
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Veloza L, Teixido C, Castrejon N, Climent F, Carrió A, Marginet M, Soldini D, González-Farré B, Ribera-Cortada I, Lopez-Guillermo A, González-Barca E, Sierra A, Herrera M, Gómez C, Garcia A, Balagué O, Campo E, Martinez A. Clinicopathological evaluation of the programmed cell death 1 (PD1)/programmed cell death-ligand 1 (PD-L1) axis in post-transplant lymphoproliferative disorders: association with Epstein-Barr virus, PD-L1 copy number alterations, and outcome. Histopathology 2019; 75:799-812. [PMID: 30861172 DOI: 10.1111/his.13857] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/04/2019] [Accepted: 03/07/2019] [Indexed: 12/25/2022]
Abstract
AIMS The clinical implications of the programmed cell death 1 (PD1)/programmed cell death-ligand 1 (PD-L1) axis in patients with post-transplant lymphoproliferative disorders are largely unknown, and its association with Epstein-Barr virus (EBV) status and PD-L1 copy number alterations (CNAs) has not been thoroughly studied. METHODS AND RESULTS PD1/PD-L1 expression was studied in 50 adult post-transplant lymphoproliferative disorders, and the correlations with PD-L1 CNAs, EBV, clinicopathological features and outcome were evaluated. Thirty-seven (74%) cases were classified as diffuse large B-cell lymphoma (DLBCL), nine (18%) cases were classified as polymorphic, and four (8%) cases were classified as classic Hodgkin lymphoma. Thirty-four cases were EBV-positive, with 29 of 34 (85%) having latency II or III, and 15 of 34 (44%) having viral replication. PD-L1 expression in tumour cells and tumour-associated macrophages was observed in 30 (60%) and 37 (74%) cases, respectively. PD1 positivity was seen in 16 (32%) cases. PD-L1 expression was associated with EBV with latency II or III (P = 0.001) and organ rejection (P = 0.04), and, in DLBCL, with non-germinal centre type DLBCL (P < 0.001). Cases with PD-L1-positive tumour cells showed a higher number of PD-L1 CNAs than PD-L1-negative cases (P = 0.001). Patients with EBV/latency III/replication and simultaneous PD-L1 expression showed the worst overall survival (P < 0.001). CONCLUSIONS The PD1/PD-L1 axis is deregulated in post-transplant lymphoproliferative disorders, with frequent PD-L1 expression and PD1 negativity. PD-L1 expression is associated with EBV latency II or III and PD-L1 CNAs, and probably reflects a proinflammatory tumour microenvironment. The combined analysis of EBV status and PD-L1 expression may help to identify deeply immunosuppressed patients who can benefit from immune reconstitution approaches.
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Affiliation(s)
- Luis Veloza
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Cristina Teixido
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Natalia Castrejon
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Fina Climent
- Department of Pathology, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Ana Carrió
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Marta Marginet
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Davide Soldini
- Institut für klinische Pathologie medica, Zürich, Switzerland
| | - Blanca González-Farré
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Inmaculada Ribera-Cortada
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Department of Pathology, Hospital Nostra Senyora de Meritxell, Escaldes-Engordany, Principat d'Andorra
| | - Armando Lopez-Guillermo
- Department of Haematology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Eva González-Barca
- Department of Clinical Haematology, Institut Català Oncologia (ICO)-Hospitalet, IDIBELL, Barcelona, Spain
| | - Adriana Sierra
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Mileyka Herrera
- Fachbereich Pathologie, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Cándida Gómez
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Adriana Garcia
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Olga Balagué
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Elias Campo
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Antonio Martinez
- Department of Pathology, Hospital Clinic, Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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48
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Wu Y, Chen W, Xu ZP, Gu W. PD-L1 Distribution and Perspective for Cancer Immunotherapy-Blockade, Knockdown, or Inhibition. Front Immunol 2019; 10:2022. [PMID: 31507611 PMCID: PMC6718566 DOI: 10.3389/fimmu.2019.02022] [Citation(s) in RCA: 254] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 08/09/2019] [Indexed: 12/31/2022] Open
Abstract
Cancer immunotherapy involves blocking the interactions between the PD-1/PD-L1 immune checkpoints with antibodies. This has shown unprecedented positive outcomes in clinics. Particularly, the PD-L1 antibody therapy has shown the efficiency in blocking membrane PD-L1 and efficacy in treating some advanced carcinoma. However, this therapy has limited effects on many solid tumors, suspecting to be relevant to PD-L1 located in other cellular compartments, where they play additional roles and are associated with poor prognosis. In this review, we highlight the advances of 3 current strategies on PD-1/PD-L1 based immunotherapy, summarize cellular distribution of PD-L1, and review the versatile functions of intracellular PD-L1. The intracellular distribution and function of PD-L1 may indicate why not all antibody blockade is able to fully stop PD-L1 biological functions and effectively inhibit tumor growth. In this regard, gene silencing may have advantages over antibody blockade on suppression of PD-L1 sources and functions. Apart from cancer cells, PD-L1 silencing on host immune cells such as APC and DC can also enhance T cell immunity, leading to tumor clearance. Moreover, the molecular regulation of PD-L1 expression in cells is being elucidated, which helps identify potential therapeutic molecules to target PD-L1 production and improve clinical outcomes. Based on our understandings of PD-L1 distribution, regulation, and function, we prospect that the more effective PD-L1-based cancer immunotherapy will be combination therapies.
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Affiliation(s)
| | | | | | - Wenyi Gu
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St. Lucia, QLD, Australia
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49
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Puła B, Salomon-Perzyński A, Prochorec-Sobieszek M, Jamroziak K. Immunochemotherapy for Richter syndrome: current insights. Immunotargets Ther 2019; 8:1-14. [PMID: 30788335 PMCID: PMC6368420 DOI: 10.2147/itt.s167456] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Richter syndrome (RS) is recognized as the development of a secondary and aggressive lymphoma during the clinical course of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Most of such histological transformations are from RS to diffuse large B-cell lymphoma (DLBCL-RS, 90%) and Hodgkin’s lymphoma (HL-RS, 10%). Histopathological examination is a prerequisite for diagnosis. It is crucial to assess the relationship between the RS clone and the underlying CLL/SLL because clonally related DLBCL-RS has a poor outcome, while clonally unrelated cases have a prognosis similar to de novo DLBCL. An anti-CD20 antibody-based immunochemotherapy is hitherto the frontline treatment of choice for DLBCL-RS; nonetheless, the results are unsatisfactory. Allogeneic stem cell transplantation should be offered to younger and fit patients as a consolidative treatment; however, the majority of the patients may not be qualified for this procedure. The HL-RS transformation has better outcomes than those of DLBCL-RS and can effectively be treated by the adriamycin, bleomycin, vinblastine, and dacarbazine regimen. Although novel agents are currently being investigated for RS, immunochemotherapy nevertheless remains a standard treatment for DLBCL-RS.
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Affiliation(s)
- Bartosz Puła
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,
| | | | - Monika Prochorec-Sobieszek
- Department of Diagnostic Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.,Department of Pathology and Laboratory Medicine, Maria Sklodowska-Curie Institute - Oncology Center, Warsaw, Poland
| | - Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,
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50
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Allan JN, Furman RR. Current trends in the management of Richter's syndrome. Int J Hematol Oncol 2019; 7:IJH09. [PMID: 30651968 PMCID: PMC6331753 DOI: 10.2217/ijh-2018-0010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/21/2018] [Indexed: 12/16/2022] Open
Abstract
Richter's syndrome (RS) is a life-threatening complication of chronic lymphocytic leukemia (CLL). While previous research has increased our knowledge on the distinct evolutionary patterns of RS and provided a deeper understanding of the risk factors and molecular events predisposing to transformation, there remain few targetable aberrations and treatment is largely ineffective. The ability to obtain deeper remissions, without selecting for deletion 17p, by using novel B-cell receptor (BCR) antagonists and bcl2 inhibition might lead to a decrease in the incidence of RS, but these agents have done little to significantly change outcomes when incorporated into treatment regimens for RS. In this review we highlight the current landscape of molecular lesions specific to RS, review the data on historical treatment options, and look to the horizon for potential opportunities in the future.
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Affiliation(s)
- John N Allan
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Richard R Furman
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
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