1
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Du J, Chen ZY, Gu XR, Wang T, Huang ZF. Bruton tyrosine kinase inhibitor-related atrial fibrillation and its implications in the treatment of B-cell lymphoma. Front Cardiovasc Med 2024; 11:1408983. [PMID: 39131702 PMCID: PMC11310794 DOI: 10.3389/fcvm.2024.1408983] [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: 03/29/2024] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Adverse events of atrial fibrillation (AF) have been commonly reported in lymphoma patients in treating Bruton's tyrosine kinase inhibitors (BTKi). The incidence rate of AF can vary depending on the specific types of BTKi and the patient population. Totally 45 published studies have revealed that the overall incidence rate of AF is 5% (95% CI 4%-7%). By performing a subtype single-rate analysis, the second-generation BTKi shows a lower AF incidence rate and lower cardiovascular toxicity. In the subtype single-rate analysis, we conclude the different AF incidence rates of Ibrutinib (10%, 95% CI 7%-13%), Acalabrutinib (4%, 95% CI 1%-6%), Orelabrutinib (0%, 95% CI 0%-1%), and Zanubrutinib (0%, 95% CI 0%-1%). The comprehensive analysis of AF inspires us to better predict and manage AF and other cardiovascular events in treating lymphoma. Meticulous evaluation, collaboration between cardiologists and hematologists, and discovery of new biomarkers are essential for its management.
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Affiliation(s)
- Jun Du
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ze-Yu Chen
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Ran Gu
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Wang
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zou-Fang Huang
- Ganzhou Key Laboratory of Hematology, Department of Hematology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
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2
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Nawaratne V, Sondhi AK, Abdel-Wahab O, Taylor J. New Means and Challenges in the Targeting of BTK. Clin Cancer Res 2024; 30:2333-2341. [PMID: 38578606 PMCID: PMC11147694 DOI: 10.1158/1078-0432.ccr-23-0409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/03/2024] [Accepted: 03/15/2024] [Indexed: 04/06/2024]
Abstract
Bruton's tyrosine kinase (BTK) is central to the survival of malignant and normal B lymphocytes and has been a crucial therapeutic target of several generations of kinase inhibitors and newly developed degraders. These new means for targeting BTK have added additional agents to the armamentarium for battling cancers dependent on B-cell receptor (BCR) signaling, including chronic lymphocytic leukemia and other non-Hodgkin lymphomas. However, the development of acquired resistance mutations to each of these classes of BTK inhibitors has led to new challenges in targeting BTK as well as novel insights into BCR signaling. The first-generation covalent BTK inhibitor ibrutinib is susceptible to mutations affecting the covalent binding site, cysteine 481 (C481). Newer noncovalent BTK inhibitors, such as pirtobrutinib, overcome C481 mutation-mediated resistance but are susceptible to other kinase domain mutations, particularly at residues Threonine 474 and Leucine 528. In addition, these novel BTK inhibitor resistance mutations have been shown biochemically and in patients to cause cross-resistance to some covalent BTK inhibitors. Importantly, newer generation covalent BTK inhibitors zanubrutinib and acalabrutinib are susceptible to the same mutations that confer resistance to noncovalent inhibitors. The BTK L528W mutation is of particular interest as it disrupts the kinase activity of BTK, rendering it kinase dead. This observation suggests that BTK may act independently of its kinase activity as a scaffold. Thus, the timely development of BTK degrading proteolysis targeting drugs has allowed for degradation, rather than just enzymatic inhibition, of BTK in B-cell lymphomas, and early clinical trials to evaluate BTK degraders are underway.
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Affiliation(s)
- Vindhya Nawaratne
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anya K. Sondhi
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami, FL, USA
| | - Omar Abdel-Wahab
- Molecular Pharmacology Program, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami, FL, USA
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3
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Lasica M, Anderson MA, Boussioutas A, Gregory GP, Hamad N, Manos K, McKelvie P, Ng M, Campbell B, Palfreyman E, Salvaris R, Weinkove R, Wight J, Opat S, Tam C. Marginal zone lymphomas: a consensus practice statement from the Australasian Lymphoma Alliance. Intern Med J 2024; 54:1017-1030. [PMID: 38881453 DOI: 10.1111/imj.16390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 03/17/2024] [Indexed: 06/18/2024]
Abstract
Marginal zone lymphomas (MZLs) are a rare, indolent group of non-Hodgkin lymphomas with different diagnostic, genetic and clinical features and therapeutic implications. The most common is extranodal MZL of mucosa-associated lymphoid tissue, followed by splenic MZL and nodal MZL. Patients with MZL generally have good outcomes with long survival rates but frequently have a relapsing/remitting course requiring several lines of therapy. The heterogeneous presentation and relapsing course present the clinician with several diagnostic and therapeutic challenges. This position statement presents evidence-based recommendations in the setting of Australia and New Zealand.
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Affiliation(s)
- Masa Lasica
- Department of Clinical Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Mary A Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
| | - Alex Boussioutas
- Department of Gastroenterology, Alfred Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
- Familial Cancer Clinic, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Gareth P Gregory
- Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Monash Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Kate Manos
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Penny McKelvie
- Department of Anatomical Pathology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Michael Ng
- GenesisCare St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Belinda Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Pathology, University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Palfreyman
- Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Ross Salvaris
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Robert Weinkove
- Te Rerenga Ora Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology and Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Joel Wight
- Department of Haematology and Bone Marrow Transplantation, Townsville University Hospital, Townsville, Queensland, Australia
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - Stephen Opat
- Monash Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Constantine Tam
- Haematology Department, Alfred Hospital, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
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4
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Silkenstedt E, Salles G, Campo E, Dreyling M. B-cell non-Hodgkin lymphomas. Lancet 2024; 403:1791-1807. [PMID: 38614113 DOI: 10.1016/s0140-6736(23)02705-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 07/31/2023] [Accepted: 11/30/2023] [Indexed: 04/15/2024]
Abstract
B-cell lymphomas occur with an incidence of 20 new cases per 100 000 people per year in high-income countries. They can affect any organ and are characterised by heterogeneous clinical presentations and courses, varying from asymptomatic, to indolent, to very aggressive cases. Since the topic of B-cell non-Hodgkin lymphomas was last reviewed in The Lancet in 2017, a deeper understanding of the biological background of this heterogeneous group of malignancies, the availability of new diagnostic methods, and the development and implementation of new targeted and immunotherapeutic approaches have improved our ability to treat patients. This Seminar provides an overview of the pathobiology, classification, and prognostication of B-cell non-Hodgkin lymphomas and summarises the current knowledge and standard of care regarding biology and clinical management of the most common subtypes of mature B-cell non-Hodgkin lymphomas. It also highlights new findings in deciphering the molecular background of disease development and the implementation of new therapeutic approaches, particularly those targeting the immune system.
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Affiliation(s)
| | - Gilles Salles
- Lymphoma Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Elias Campo
- Department of Pathology, Hospital Clinic, Institute for Biomedical Research August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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5
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Phillips TJ, Avigdor A, Gurion R, Patti C, Corradini P, Tani M, Mehta A, Lossos IS, Zinzani PL, Thieblemont C, Jurczak W, Zheng F, Rappold E, Zhao W, Jiang P, Johnson P. A phase 2 study of the PI3Kδ inhibitor parsaclisib in relapsed and refractory marginal zone lymphoma (CITADEL-204). Blood Adv 2024; 8:867-877. [PMID: 38113459 PMCID: PMC10875254 DOI: 10.1182/bloodadvances.2023010648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023] Open
Abstract
ABSTRACT Parsaclisib, a potent and highly selective PI3Kδ inhibitor, has shown clinical benefit in patients with relapsed or refractory (R/R) B-cell lymphomas. The phase 2 CITADEL-204 study (NCT03144674, EudraCT 2017-000970-12) assessed efficacy and safety of parsaclisib in Bruton tyrosine kinase (BTK) inhibitor-experienced (cohort 1) or BTK inhibitor-naive (cohort 2) patients with R/R marginal zone lymphoma (MZL). Patients aged ≥18 years with histologically confirmed R/R MZL, treated with ≥1 prior systemic therapy (including ≥1 anti-CD20 antibody) received parsaclisib 20 mg once daily for 8 weeks then 20 mg once weekly (weekly dosing group [WG]) or parsaclisib 20 mg once daily for 8 weeks then 2.5 mg once daily (daily dosing group [DG]); DG was selected for further assessment. Primary end point of the study was objective response rate (ORR). Owing to slower than expected recruitment, cohort 1 was closed with 10 patients (WG, n = 4; DG, n = 6) enrolled. Based on a planned interim analysis in cohort 2, the futility boundary was not crossed, and enrollment continued to study completion. At data cutoff (15 January 2021), 100 patients were enrolled and treated in cohort 2 (WG, n = 28; DG, n = 72). In the DG, the ORR was 58.3% (95% confidence interval [CI], 46.1-69.8), with a complete response rate of 4.2% (95% CI, 0.9-11.7); the lower bound of the ORR 95% CI exceeded the protocol-defined threshold of 40%. The median duration of response was 12.2 months (95% CI, 8.1-17.5) and progression-free survival was 16.5 months (95% CI, 11.5-20.6); median overall survival was not reached. The most common treatment-emergent adverse events (TEAEs) among all patients were diarrhea (47.0%), cough (23.0%), and rash (18.0%); the most common grade ≥3 TEAEs included diarrhea (12.0%), neutropenia, and pneumonia (9.0% each). TEAEs led to dose interruptions, reductions, and discontinuations in 56.0%, 16.0%, and 29.0% of all patients, respectively. Durable responses and an overall manageable safety profile were demonstrated in patients with R/R MZL treated with parsaclisib monotherapy.
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Affiliation(s)
| | - Abraham Avigdor
- Institute of Hematology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Gurion
- Institute of Hematology, Rabin Medical Center & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Caterina Patti
- Department of Hematology I, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Paolo Corradini
- University of Milano Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Monica Tani
- Ospedale di Ravenna, Azienda Unità Sanitaria Locale della Romagna, Ravenna, Italy
| | | | - Izidore S. Lossos
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli,” Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Catherine Thieblemont
- Université de Paris; APHP, Hôpital Saint-Louis, Hémato-oncologie, Paris Diderot, Paris, France
| | - Wojciech Jurczak
- Maria Sklodowska-Curie National Research Institute of Oncology, Kraków, Poland
| | | | | | | | | | - Peter Johnson
- School of Cancer Sciences, University of Southampton, Southampton, United Kingdom
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6
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Wang H, Wan X, Zhang Y, Guo J, Bai O. Advances in the treatment of relapsed/refractory marginal zone lymphoma. Front Oncol 2024; 14:1327309. [PMID: 38333686 PMCID: PMC10850340 DOI: 10.3389/fonc.2024.1327309] [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: 10/24/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024] Open
Abstract
Marginal zone lymphoma (MZL) is the second most common subtype of inert B-cell non-Hodgkin's lymphoma, accounting for 5-15% of non-Hodgkin's lymphoma cases. Patients with MZL have a long survival period, with a median survival of >10 years, and patients treated with a combination of anti-CD20 monoclonal antibody can achieve an overall effective rate of 81%. However, 20% of patients with MZL show relapse or experience disease progression within 2 years, with a median survival of only 3-5 years. Currently, the treatment options for patients with relapsed/refractory (R/R) MZL are limited, underscoring the pressing need for novel therapeutic drugs. The advent of novel anti-CD20 monoclonal antibodies, small molecule kinase inhibitors, immunomodulators, and other therapeutic strategies has ushered in a new era in the treatment of R/R MZL. Our objective is to summarize the existing treatment strategies, including immunotherapy and the emergent targeted therapies, and to evaluate their effectiveness and safety in the management of R/R MZL. By doing so, we aim to provide a clear understanding of the therapeutic landscape for R/R MZL, and to guide future research directions toward improving the prognosis and quality of life for patients afflicted with this challenging disease.
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Affiliation(s)
| | | | | | | | - Ou Bai
- Department of Hematology, The First Hospital of Jilin University, Changchun, Jilin, China
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7
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Zinzani PL, Mauro FR, Tedeschi A, Varettoni M, Zaja F, Barosi G. Unmet clinical needs in the use of zanubrutinib in malignant lymphomas (Waldenström macroglobulinemia, marginal zone lymphoma and mantle cell lymphoma): A consensus-based position paper from an ad hoc expert panel. Hematol Oncol 2023; 41:795-808. [PMID: 37165730 DOI: 10.1002/hon.3172] [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: 02/10/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
Zanubrutinib has been approved for the treatment of patients with different lymphoproliferative disorders, and now represents a major breakthrough in the treatment of patients resistant or relapsing after the recommended therapies. Because few systematic studies or comparative randomized clinical trials have been conducted, optimal use of the drug in approved indications is challenging, and questions are emerging on its use in earlier stages of the disorders. This article presents the results of group discussion among an ad hoc constituted panel of experts aimed at identifying and addressing unmet clinical needs (UCNs) in the use of zanubrutinib in the lymphomas which have received the approval of use, specifically Waldenström macroglubulinemia, marginal zone lymphoma and mantle cell lymphoma. Key UCNs were selected according to the criterion of clinical relevance using the Delphi process. The panel produced recommendations and proposals for new studies for the management of the identified UCNs. These recommendations are intended for use not only by expert centers but above all by not experienced hematologists as well as general practitioners.
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Affiliation(s)
- Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia 'Seràgnoli', Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Roma, Italy
| | - Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marzia Varettoni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Zaja
- Dipartimento Clinico di Scienze Mediche, Chirurgiche e della Salute, Università degli Studi di Trieste, Trieste, Italy
- Unità Complessa Operativa (UCO) Ematologia, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis, IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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8
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Deng L, Li Z, Zhang H, Huang H, Hu J, Liu L, Liu T, Jin J, Zhu Z, Li W, Huang Z, Huang W, Zhou K, Yang H, Zhang M, Ding K, Zhou H, Hu Y, Shuang Y, Cao J, Gao S, Li D, Sun Z, Zhang Q, Yi S, Ji C, Zhang L, Hou C, Du Y, Wang W, Zhao R, Song Y, Zhu J. Orelabrutinib for the treatment of relapsed or refractory marginal zone lymphoma: A phase 2, multicenter, open-label study. Am J Hematol 2023; 98:1742-1750. [PMID: 37647123 DOI: 10.1002/ajh.27064] [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: 05/10/2023] [Revised: 08/06/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023]
Abstract
Marginal zone lymphoma (MZL) is an indolent type of non-Hodgkin lymphoma that develops through pathological B cell receptor signaling. Orelabrutinib, a new-generation oral small molecule Bruton's tyrosine kinase inhibitor, was evaluated in relapsed/refractory (r/r) MZL patients. Previously treated r/r MZL patients received orelabrutinib 150 mg once daily in a phase 2, multicenter, single-arm study conducted in China. The primary endpoint was overall response rate (ORR) assessed by an Independent Review Committee (IRC) based on the Lugano 2014 classification. Other efficacy, safety, and pharmacokinetic profiles were evaluated as secondary outcome measures. A total of 111 patients were enrolled, of which 90 patients had MZL confirmed by central pathology review, who were mainly with extra-nodal MZL of mucosa-associated lymphoid tissue (MALT, 46.7%) and nodal MZL (35.6%). The majority had late-stage disease, with stage IV accounting for 75.6%. After a median follow-up duration of 24.3 months, the IRC-assessed ORR was 58.9% (95% confidence interval [CI], 48.0-69.2), with rates of complete response and partial response being 11.1% and 47.8%, respectively. The IRC-assessed median duration of response was 34.3 months, and the IRC-assessed median progression-free survival (PFS) was not reached with a 12-month PFS rate of 82.8% (95% CI, 72.6-89.5). The rate of overall survival at 12 months was 91.0% (95% CI, 82.8-95.4). Common all-grade treatment-related adverse events (TRAEs) included anemia (27.9%), neutrophil count decrease (23.4%), white blood cell count decrease (18.0%), platelet count decrease (17.1%), blood present in urine (16.2%), rash (14.4%), and upper respiratory tract infection (10.8%). Thirty-four patients (30.6%) experienced grade 3 or higher TRAEs. Serious TRAEs occurred in 18 patients (16.2%), of which pneumonia (5.4%) was the most common. Seven patients (6.3%) discontinued orelabrutinib due to TRAEs. Orelabrutinib demonstrated high response rates with durable disease remission and was well tolerated in Chinese patients with r/r MZL.
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Affiliation(s)
- Lijuan Deng
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Zhiming Li
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huilai Zhang
- Department of Lymphoma, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Haiwen Huang
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianda Hu
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Lihong Liu
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ting Liu
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zunmin Zhu
- Department of Hematology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenyu Li
- Department of Lymphoma, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Zhenqian Huang
- Department of Hematology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wenrong Huang
- Department of Hematology, The Fifth Medical Center of the Chinese People's Liberation Army General Hospital, Beijing, China
| | - Keshu Zhou
- Department of Hematology, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, China
| | - Haiyan Yang
- Department of Oncology, Zhejiang Cancer Hospital, Hangzhou, China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kaiyang Ding
- Department of Hematological Oncology, Anhui Province Cancer Hospital, Hefei, China
| | - Hui Zhou
- Department of Lymphoma and Hematology, Hunan Cancer Hospital, Changsha, China
| | - Yu Hu
- Department of Hematology, Union Hospital Tongji Medical College Huazhong University of Science and Technology, Wuhan, China
| | - Yuerong Shuang
- Department of Hematology and Lymphoma, Jiangxi Cancer Hospital, Nanchang, China
| | - Junning Cao
- Department of Medical Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Dengju Li
- Department of Hematology, Tongji Hospital Tongji Medical College Huazhong University of Science and Technology, Wuhan, China
| | - Zimin Sun
- Department of Hematology, Anhui Provincial Hospital, Hefei, China
| | - Qingyuan Zhang
- Department of Internal Medicine-Oncology, Cancer Hospital of Harbin Medical University, Harbin, China
| | - Shuhua Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Chunyan Ji
- Department of Oncology Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Liansheng Zhang
- Department of Oncology Medicine, Lanzhou University Second Hospital, Lanzhou, China
| | - Cheng Hou
- Beijing InnoCare Pharma Tech Co., Ltd., Beijing, China
| | - Yue Du
- Beijing InnoCare Pharma Tech Co., Ltd., Beijing, China
| | - Weige Wang
- Beijing InnoCare Pharma Tech Co., Ltd., Beijing, China
| | - Renbin Zhao
- Beijing InnoCare Pharma Tech Co., Ltd., Beijing, China
| | - Yuqin Song
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Jun Zhu
- Department of Lymphoma, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
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9
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Song Y, Wu SJ, Shen Z, Zhao D, Chan TSY, Huang H, Qiu L, Li J, Tan TD, Zhu J, Song Y, Huang WH, Zhao W, Liu HSY, Xu W, Chen N, Ma J, Chang CS, Tse EWC. Chinese expert consensus on Bruton tyrosine kinase inhibitors in the treatment of B-cell malignancies. Exp Hematol Oncol 2023; 12:92. [PMID: 37845755 PMCID: PMC10578030 DOI: 10.1186/s40164-023-00448-5] [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: 07/19/2023] [Accepted: 09/15/2023] [Indexed: 10/18/2023] Open
Abstract
Targeted therapy with Bruton tyrosine kinase (BTK) inhibitors have revolutionized the treatment of patients with various B-cell malignancies. BTK inhibitors such as ibrutinib, zanubrutinib, orelabrutinib, and acalabrutinib have shown good clinical efficacy and better safety profiles than those of traditional chemotherapy and chemoimmunotherapy regimens. Multiple studies on new BTK inhibitors are ongoing, which may provide more therapeutic options for the treatment of B-cell malignancies. Considering the unmet need of evidence on BTK inhibitors in all clinical settings and to standardize the use of BTK inhibitors available in mainland China, Taiwan, Hong Kong, and Macau regions, this consensus has been formulated for the treatment of various B-cell malignancies based on the clinical practice and available evidences on the use of BTK inhibitors. The recommendations of this consensus will provide guidance to physicians and clinical researchers on the effective treatment of B-cell malignancies with BTK inhibitors.
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Affiliation(s)
- Yuqin Song
- Peking University Cancer Hospital and Institute, Beijing, China
| | - Shang-Ju Wu
- Hematology Division, Department of Internal Medicine, National Taiwan University Hospital, Taiwan, China
| | - Zhixiang Shen
- Shanghai Jiaotong University Affiliated Ruijin Hospital, Shanghai, China
| | - Donglu Zhao
- Harbin Hematology and Oncology Institute, Heilongjiang, 150007, China
| | | | | | - Lugui Qiu
- Institute of Hematology and Blood Diseases Hospital, Tianjing, China
| | - Jianyong Li
- Jiangsu Provincial People's Hospital, Jiangsu, China
| | - Tran-der Tan
- Department of Hematology and Medical Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taiwan, China
| | - Jun Zhu
- Peking University Cancer Hospital and Institute, Beijing, China
| | - Yongping Song
- The First Affiliated Hospital of Zhengzhou University, Henan, China
| | - Wei-Han Huang
- Department of Clinical Pathology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, China
| | - Weili Zhao
- Shanghai Jiaotong University Affiliated Ruijin Hospital, Shanghai, China
| | | | - Wei Xu
- Jiangsu Provincial People's Hospital, Jiangsu, China
| | - Naizhi Chen
- Macau Society of Hematology and Oncology, Macau, China
| | - Jun Ma
- Harbin Hematology and Oncology Institute, Heilongjiang, 150007, China.
| | - Cheng-Shyong Chang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Bing Show Chwan Memorial Hospital, Taiwan, China.
- Department of Healthcare Administration, Central Taiwan University of Science and Technology, Taiwan, China.
| | - Eric Wai Choi Tse
- Department of Medicine, School of Clinical Medicine, University of Hong Kong, Hong Kong, China.
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10
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Cheah CY, Seymour JF. Marginal zone lymphoma: 2023 update on diagnosis and management. Am J Hematol 2023; 98:1645-1657. [PMID: 37605344 DOI: 10.1002/ajh.27058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023]
Abstract
DISEASE OVERVIEW Marginal zone lymphomas (MZL) are collectively the second most common type of indolent lymphoma. DIAGNOSIS Three subtypes of MZL are recognized: splenic, extranodal, and nodal. The diagnosis is secured following biopsy of an involved nodal or extranodal site demonstrating a clonal B-cell infiltrate with CD5 and CD10 negative immunophenotype most common. Some cases will features IgM paraprotein, but MYD88 L256P mutations are less frequent than in Waldenstrom macroglobulinemia. Prognostication Several prognostic models have been developed, including the MALT-IPI and the MZL-IPI. The latter is broadly applicable across MZL subtypes and incorporates elevated serum LDH, anemia, lymphopenia, thrombocytopenia and nodal or disseminated subtypes as independent predictors of outcome. TREATMENT We discuss suggested approach to therapy for both early and advanced-stage disease, with reference to chemo-immunotherapy, radiotherapy, and emerging treatments in relapsed/refractory disease such as BTK inhibitors.
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Affiliation(s)
- Chan Y Cheah
- Department of Haematology, Sir Charles Gairdner Hospital, Nedlands, Australia
- Medical School, University of Western Australia, Crawley, Australia
| | - John F Seymour
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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11
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Mak JWY, Law AWH, Law KWT, Ho R, Cheung CKM, Law MF. Prevention and management of hepatitis B virus reactivation in patients with hematological malignancies in the targeted therapy era. World J Gastroenterol 2023; 29:4942-4961. [PMID: 37731995 PMCID: PMC10507505 DOI: 10.3748/wjg.v29.i33.4942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/22/2023] [Accepted: 08/15/2023] [Indexed: 09/01/2023] Open
Abstract
Hepatitis due to hepatitis B virus (HBV) reactivation can be serious and potentially fatal, but is preventable. HBV reactivation is most commonly reported in patients receiving chemotherapy, especially rituximab-containing therapy for hematological malignancies and those receiving stem cell transplantation. Patients with inactive and even resolved HBV infection still have persistence of HBV genomes in the liver. The expression of these silent genomes is controlled by the immune system. Suppression or ablation of immune cells, most importantly B cells, may lead to reactivation of seemingly resolved HBV infection. Thus, all patients with hematological malignancies receiving anticancer therapy should be screened for active or resolved HBV infection by blood tests for hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen. Patients found to be positive for HBsAg should be given prophylactic antiviral therapy. For patients with resolved HBV infection, there are two approaches. The first is pre-emptive therapy guided by serial HBV DNA monitoring, and treatment with antiviral therapy as soon as HBV DNA becomes detectable. The second approach is prophylactic antiviral therapy, particularly for patients receiving high-risk therapy, especially anti-CD20 monoclonal antibody or hematopoietic stem cell transplantation. Entecavir and tenofovir are the preferred antiviral choices. Many new effective therapies for hematological malignancies have been introduced in the past decade, for example, chimeric antigen receptor (CAR)-T cell therapy, novel monoclonal antibodies, bispecific antibody drug conjugates, and small molecule inhibitors, which may be associated with HBV reactivation. Although there is limited evidence to guide the optimal preventive measures, we recommend antiviral prophylaxis in HBsAg-positive patients receiving novel treatments, including Bruton's tyrosine kinase inhibitors, B-cell lymphoma 2 inhibitors, and CAR-T cell therapy. Further studies are needed to determine the risk of HBV reactivation with these agents and the best prophylactic strategy.
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Affiliation(s)
- Joyce Wing Yan Mak
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
| | | | | | - Rita Ho
- Department of Medicine, North District Hospital, Hong Kong 852, China
| | - Carmen Ka Man Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
| | - Man Fai Law
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong 852, China
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12
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Tatarczuch M, Waltham M, Shortt J, Polekhina G, Hawkes EA, Ho SJ, Trotman J, Brasacchio D, Co M, Li J, Ramakrishnan V, Dunne K, Opat SS, Gregory GP. Molecular associations of response to the new-generation BTK inhibitor zanubrutinib in marginal zone lymphoma. Blood Adv 2023; 7:3531-3539. [PMID: 36947202 PMCID: PMC10368859 DOI: 10.1182/bloodadvances.2022009412] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/09/2023] [Accepted: 02/26/2023] [Indexed: 03/23/2023] Open
Abstract
Using tissue whole exome sequencing (WES) and circulating tumor cell-free DNA (ctDNA), this Australasian Leukaemia & Lymphoma Group translational study sought to characterize primary and acquired molecular determinants of response and resistance of marginal zone lymphoma (MZL) to zanubrutinib for patients treated in the MAGNOLIA clinical trial. WES was performed on baseline tumor samples obtained from 18 patients. For 7 patients, ctDNA sequence was interrogated using a bespoke hybrid-capture next-generation sequencing assay for 48 targeted genes. Somatic mutations were correlated with objective response data and survival analysis using Fisher exact test and Kaplan-Meier (log-rank) method, respectively. Baseline WES identified mutations in 33 of 48 (69%) prioritized genes. NF-κB, NOTCH, or B-cell receptor (BCR) pathway genes were implicated in samples from 16 of 18 patients (89%). KMT2D mutations (n = 11) were most common, followed by FAT1 (n = 9), NOTCH1, NOTCH2, TNFAIP3 (n = 5), and MYD88 (n = 4) mutations. MYD88 or TNFAIP3 mutations correlated with improved progression-free survival (PFS). KMT2D mutations trended to worse PFS. Acquired resistance mutations PLCG2 (R665W/R742P) and BTK (C481Y/C481F) were detected in 2 patients whose disease progressed. A BTK E41K noncatalytic activating mutation was identified before treatment in 1 patient who was zanubrutinib-refractory. MYD88, TNFAIP3, and KMT2D mutations correlate with PFS in patients with relapsed/refractory MZL treated with zanubrutinib. Detection of acquired BTK and PLCG2 mutations in ctDNA while on therapy is feasible and may herald clinical disease progression. This trial was registered at https://anzctr.org.au/ as #ACTRN12619000024145.
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Affiliation(s)
- Maciej Tatarczuch
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | - Mark Waltham
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | - Jake Shortt
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | - Galina Polekhina
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Eliza A. Hawkes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Eastern Health, Melbourne, VIC, Australia
- Olivia Newton John Cancer Research Institute at Austin Health, Melbourne, VIC, Australia
| | - Shir-Jing Ho
- St George Hospital, Sydney, NSW, Australia
- St George & Sutherland Clinical School, University of NSW, Sydney, Australia
| | - Judith Trotman
- Department of Hematology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Daniella Brasacchio
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | | | | | | | - Karin Dunne
- Australasian Leukaemia & Lymphoma Group, Melbourne, VIC, Australia
| | - Stephen S. Opat
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | - Gareth P. Gregory
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
| | - Australasian Leukaemia and Lymphoma Group
- Monash Hematology, Monash Health, Melbourne, VIC, Australia
- Blood Cancer Therapeutics Laboratory, Department of Medicine, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing & Health Sciences, Monash University, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Eastern Health, Melbourne, VIC, Australia
- Olivia Newton John Cancer Research Institute at Austin Health, Melbourne, VIC, Australia
- St George Hospital, Sydney, NSW, Australia
- St George & Sutherland Clinical School, University of NSW, Sydney, Australia
- Department of Hematology, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
- BeiGene Co Ltd, USA Inc, San Mateo, CA
- Australasian Leukaemia & Lymphoma Group, Melbourne, VIC, Australia
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13
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Rivero A, Mozas P, Magnano L, López-Guillermo A. Novel targeted drugs for follicular and marginal zone lymphoma: a comprehensive review. Front Oncol 2023; 13:1170394. [PMID: 37207160 PMCID: PMC10189145 DOI: 10.3389/fonc.2023.1170394] [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: 02/20/2023] [Accepted: 04/03/2023] [Indexed: 05/21/2023] Open
Abstract
Although mostly incurable, indolent non-Hodgkin lymphomas (iNHL) are chronic diseases with a median overall survival approaching 20 years. In recent years, important advances in the knowledge of the biology of these lymphomas have led to the development of new drugs, mostly chemotherapy-free, with promising outcomes. With a median age of around 70 years at diagnosis, many patients with iNHL suffer from comorbid conditions that may limit treatment options. Therefore, nowadays, in the transition towards personalized medicine, several challenges lie ahead, such as identifying predictive markers for the selection of treatment, the adequate sequencing of available therapies, and the management of new and accumulated toxicities. In this review, we include a perspective on recent therapeutic advances in follicular and marginal zone lymphoma. We describe emerging data on approved and emerging novel therapies, such as targeted therapies (PI3K inhibitors, BTK inhibitors, EZH2 inhibitors), monoclonal antibodies and antibody-drug conjugates. Finally, we describe immune-directed approaches such as combinations with lenalidomide or the even more innovative bispecific T-cell engagers and chimeric antigen receptor T-cell therapy, which can achieve a high rate of durable responses with manageable toxicities, further obviating the need for chemotherapy.
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Affiliation(s)
- Andrea Rivero
- Department of Hematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Mozas
- Department of Hematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Magnano
- Department of Hematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Armando López-Guillermo
- Department of Hematology, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Universitat de Barcelona, Barcelona, Spain
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14
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Alderuccio JP, Lossos IS. Enhancing prognostication and personalizing treatment of extranodal marginal zone lymphoma. Expert Rev Hematol 2023; 16:333-348. [PMID: 37086394 PMCID: PMC10183153 DOI: 10.1080/17474086.2023.2206557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/20/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue is an indolent lymphoma originating from marginal zone B-cells and associated with chronic inflammation. EMZL demonstrates distinct genomic alterations according to the primary extranodal site of disease but commonly affects signaling pathways including NF-ĸB, B-cell receptor, and NOTCH. Treatment with radiation therapy is commonly implemented in localized diseases, and multiple agents are available for patients with advanced-stage diseases in need of therapy. Bendamustine with rituximab is a frontline platform associated with high efficacy. AREAS COVERED Clinical features, diagnosis, genomics, models enabling risk stratification, treatment options, and future directions. EXPERT OPINION The lack of consistent genotyping profile in EMZL precludes the development of tissue and circulatory biomarkers for the diagnosis, risk stratification, and monitoring of minimal residual disease. Furthermore, the biological heterogeneity observed in extranodal sites associated with overall limited genomic data prevents the testing of druggable pathways aiming for a personalized treatment approach. Future clinical trials should focus on EMZL considering the unique clinical characteristics in the eligibility criteria and response assessment to better inform efficacy of novel agents and delineate sequences of therapies.
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Affiliation(s)
| | - Izidore S. Lossos
- Department of Medicine, Division of Hematology
- Department of Molecular and Cellular Pharmacology, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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15
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Merli M, Arcaini L. Management of marginal zone lymphomas. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:676-687. [PMID: 36485086 PMCID: PMC9901419 DOI: 10.1182/hematology.2022000362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Marginal zone lymphomas (MZLs) represent about 7% of B-cell non-Hodgkin lymphomas and include 3 different subtypes-namely, extranodal (EMZL), nodal, and splenic (SMZL). The initial assessment requires specific diagnostic and staging procedures depending on organ-related peculiarities. In particular, although positron emission tomography/computed tomography was not initially recommended, recent data have reassessed its role in the routine staging of MZL, especially when only localized treatment is planned or there is a suspicion of histologic transformation. Recent findings have improved the risk stratification of MZL patients, highlighting the association of early progression after frontline therapy with worse overall survival. A significant fraction of MZL cases may be related to specific bacterial (ie, Helicobacter pylori in gastric EMZL) or viral infections (hepatis C virus), and in the earlier phases of disease, a variable percentage of patients may respond to anti-infective therapy. Involved-site radiotherapy has a central role in the management of localized EMZL not amenable to or not responding to anti-infective therapy. Although rituximab-based treatments (bendamustine- rituximab in advanced EMZL or rituximab monotherapy in SMZL) have demonstrated favorable results, the current therapeutic scenario is predicted to rapidly change as emerging novel agents, especially Bruton's tyrosine kinase inhibitors, have demonstrated promising efficacy and safety profiles, leading to their approval in the relapsed setting. Moreover, a large variety of novel agents (phosphatidylinositol 3-kinase inhibitors, chimeric antigen receptor T-cells, bispecific antibodies) are being tested in MZL patients with encouraging preliminary results.
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Affiliation(s)
- Michele Merli
- Division of Hematology, University Hospital Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Luca Arcaini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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