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Qin S, Jiang R, Dai L, Miao Y, Sha Y, Qiu T, Ding C, Wang Z, Shi C, Xia Y, Fan L, Xu W, Li J, Zhu H. Venetoclax plus dose-adjusted R-EPOCH (VR-DA-EPOCH) or G-EPOCH bridging to subsequent cellular therapy for the patients with transformed lymphoma a single center clinical experience. Ann Hematol 2024; 103:1635-1642. [PMID: 38246951 PMCID: PMC11009738 DOI: 10.1007/s00277-024-05618-x] [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: 08/20/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Indolent lymphoma, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and follicular lymphoma (FL), can undergo histological transformation into an aggressive subtype, typically diffuse large B-cell lymphoma (DLBCL). The prognosis of transformed lymphoma is poor. In this study, we reported the efficacy and toxicity of a combination of venetoclax, dose-adjusted rituximab or obinutuzumab, etoposide, prednisone, vincristine, doxorubicin, and cyclophosphamide (VR-DA-EPOCH or VG-DA-EPOCH) in 11 patients with biopsy-proven histology transformation into DLBCL, including 8 patients with RT and 3 with transformed FL (tFL). The study was conducted between October 2019 and March 2023 at our single center. The median age of participants at enrolment was 53 years. Six patients (85.7%, 6/7) achieved complete remission (CR) at the end of treatment. The best overall response rate (ORR) and CR rate were both 72.7%, respectively. Two patients received autologous hemopoietic stem cell transplant (ASCT) while two patients received ASCT concurrently with CAR-T therapy for consolidation. With a median follow-up of 13.5 (range, 2.4-29.8) months after enrollment, the median event-free survival, progression-free survival, and overall survival were 9.4, 11.5, and 17.5 months, respectively. Hematologic toxicities of grade ≥3 consisted of neutropenia (90.9%, 10/11), thrombocytopenia (63.6%, 7/11), and febrile neutropenia (54.5%, 6/11). In conclusion, VR-DA-EPOCH or VG-DA-EPOCH was a promising strategy to achieve an early remission, bridging to cellular therapy within this population.
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Affiliation(s)
- Shuchao Qin
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Rui Jiang
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Luomengjia Dai
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Yi Miao
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Yeqin Sha
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Tonglu Qiu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Chongyang Ding
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Zhen Wang
- Department of Pathology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Chuanbing Shi
- Department of Pathology, Pukou People's Hospital, Nanjing, 211800, Jiangsu, China
| | - Yi Xia
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Lei Fan
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Wei Xu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China
| | - Huayuan Zhu
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, 210029, Jiangsu, China.
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Barrett A, Appleby N, Dreau H, Fox CP, Munir T, Eyre TA. Richter's transformation: Transforming the clinical landscape. Blood Rev 2024; 64:101163. [PMID: 38097488 DOI: 10.1016/j.blre.2023.101163] [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: 10/10/2023] [Revised: 11/22/2023] [Accepted: 12/08/2023] [Indexed: 03/12/2024]
Abstract
Richter transformation (RT) represents an aggressive histological transformation from chronic lymphocytic leukaemia, most often to a large B cell lymphoma. It is characterised by chemo-resistance and subsequent short survival. Drug development has struggled over recent years in light of the aggressive kinetics of the disease, lack of pivotal registrational trials and relative rarity of the phenomenon. In this review we will highlight the diagnostic and therapeutic challenges of managing patients with RT as well as taking a look to the future therapeutic landscape. Highly active therapies developed across B cell malignancies are starting to impact this field, with T-cell activation therapies (CAR-T, bispecific antibodies), antibody-drug conjugates, and novel small molecule inhibitor combinations (e.g. BTKi-BCL2i) being actively studied. We will highlight the data supporting these developments and look to the studies to come to provide hope for patients suffering from this devastating disease.
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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/diagnosis
- Lymphoma, Large B-Cell, Diffuse/therapy
- Cell Transformation, Neoplastic
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Affiliation(s)
- A Barrett
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - N Appleby
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - H Dreau
- Oxford Molecular Diagnostic Centre, Oxford, United Kingdom
| | - C P Fox
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - T Munir
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - T A Eyre
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
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3
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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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4
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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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5
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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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6
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Levy Yurkovski I, Tadmor T. Accelerated Chronic Lymphocytic Leukemia and Richter Transformation in the Era of Novel Agents. Acta Haematol 2023; 147:73-83. [PMID: 37666234 DOI: 10.1159/000533664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 08/02/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Tremendous developments in the field of chronic lymphocytic leukemia (CLL) in recent years have led to a revolutionary change in the treatment approach, which today is based on targeted treatments with a good response and optimal prognosis. Nevertheless, CLL can present or progress to "accelerated CLL" (A-CLL) or to "Richter transformation" (RT) and these two entities have a more aggressive course and are still characterized by challenges in the fields of diagnosis and therapy. In the current review, we summarized the latest knowledge in terms of diagnostic approaches to A-CLL, available treatments and clinical trials, for both A-CLL and RT which still pose an unmet need and require additional basic and clinical investigations. SUMMARY A-CLL is a rare and underdiagnosed entity that probably stands in the "gray zone" between CLL and RT, generally holding an intermediate prognosis. Its diagnosis is mainly based on histological findings including expanded proliferation centers, increased mitotic activity, and/or high Ki-67 index. Due to its rarity, its treatment approach has still not been defined, but it seems that novel agents, especially Bruton tyrosine kinase inhibitors (BTKi), are effective. As for RT, the standard therapy still consists of chemo-immunotherapy followed by stem-cell transplantation for fit responders with a dismal prognosis. New approaches are recently adopted including B-cell inhibition via novel agents (BTKi, venetoclax), T-cell engagers (checkpoint inhibitors, bispecific antibodies [BiTe] or the chimeric antigen receptor [CAR] technology), antibody-drug conjugates, or drug combinations. Although both CAR-T and BiTe seem promising, especially when combined with BTKi, evidence is still insufficient, and patients should generally be recruited in clinical trials. KEY MESSAGES The field of CLL has been a subject of major advances in recent years, but A-CLL and RT remain topics of "unmet need" and require further studies to identify the best diagnostic approach and a more effective treatment.
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Affiliation(s)
- Ilana Levy Yurkovski
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
- The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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7
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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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8
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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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9
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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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10
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Ryan CE, Davids MS. Practical Management of Richter Transformation in 2023 and Beyond. Am Soc Clin Oncol Educ Book 2023; 43:e390804. [PMID: 37141545 DOI: 10.1200/edbk_390804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
While the past decade has witnessed unprecedented progress for patients with chronic lymphocytic leukemia (CLL), outcomes for patients with Richter transformation (RT) remain dismal. Multiagent chemoimmunotherapy regimens, such as rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone, are commonly used, although outcomes are far poorer than observed with the same regimens used in de novo diffuse large B-cell lymphoma. The revolutionary targeted therapies approved for CLL, such as inhibitors of Bruton tyrosine kinase and B-cell leukemia/lymphoma-2, have limited activity in RT as monotherapy, and initial promising activity of checkpoint blockade antibodies was also eventually found to be ineffective as monotherapy for most patients. Over the past few years, as outcomes for patients with CLL improved, there has been a growing focus of the research community on improving our biological understanding of the underlying pathophysiology of RT and on translating these new insights into rational combination strategies that are poised to improve therapeutic outcomes. Here, we present a brief overview of the biology and diagnosis of RT, as well as prognostic considerations, before providing a summary of the data supporting various therapies that have been recently studied in RT. We then turn our attention to the horizon and describe several of the promising novel approaches under investigation to treat this challenging disease.
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Affiliation(s)
- Christine E Ryan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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11
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Obinutuzumab, High-Dose Methylprednisolone (HDMP), and Lenalidomide for the Treatment of Patients with Richter's Syndrome. Cancers (Basel) 2022; 14:cancers14246035. [PMID: 36551520 PMCID: PMC9775482 DOI: 10.3390/cancers14246035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
Background: For patients with Richter's Syndrome (RS), a durable response is rarely achieved with standard therapies. Significant efforts have focused on the development of novel treatments with reduced toxicity. We describe our experience using the novel combination of obinutuzumab, high-dose methylprednisolone (HDMP) and lenalidomide (len) in patients with RS. Patients and Methods: Eligible patients included adults with biopsy-proven RS. Patients received obinutuzumab 1000 mg × 8 doses. All patients received HDMP 1000 mg/m2 on days 1-5 of cycles 1-4. Patients were administered len PO daily, starting at a dose of 5 mg. Starting on C2D1, the dose increased every 2 weeks in 5 mg increments to a maximum of 25 mg PO daily. Results: Seven patients were treated. The median dose of len was 10 mg and the median number of cycles of treatment completed was 2. The most common grade 3/4 adverse events were neutropenia (29%) and pulmonary embolism (29%). The overall response rate for the entire cohort was 43% (95% CI, 10-82%). All patients who achieved a response underwent consolidative autologous or allogeneic stem cell transplant and remain in remission to date. Conclusions: The combination of obinutuzumab, HDMP, and len is a well-tolerated, outpatient regimen that could serve as a bridge to transplantation, or as palliation for transplant-ineligible patients with RS.
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12
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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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13
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Richter Transformation in Chronic Lymphocytic Leukemia: Update in the Era of Novel Agents. Cancers (Basel) 2021; 13:cancers13205141. [PMID: 34680290 PMCID: PMC8533993 DOI: 10.3390/cancers13205141] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 01/09/2023] Open
Abstract
Richter transformation (RT) is a poorly understood complication of chronic lymphocytic leukemia (CLL) with a dismal prognosis. It is associated with a switch in histopathology and biology, generally with a transformation of the original CLL clone to diffuse large B-cell lymphoma (DLBCL) or less frequently to Hodgkin's variant of Richter transformation (HVRT). It occurs in 2-10% of CLL patients, with an incidence rate of 0.5-1% per year, and may develop in treatment-naïve patients, although it is more common following therapy. In recent years, there has been a deeper understanding of the molecular pathogenesis of RT that involves the inactivation of the TP53 tumor suppressor gene in 50-60% of cases and the activation of aberrations of NOTCH1 and MYC pathways in about 30% of cases. Compared to the preceding CLL, 80% of cases with DLBCL-RT and 30% of HVRT harbor the same IGHV-D-J rearrangements, indicating a clonal evolution of the disease, while the remaining cases represent de novo lymphomas that are clonally unrelated. Despite advances in understanding the molecular variations and the pathogenesis of the disease, there is still no significant improvement in patient outcomes. However, if no clinical trials were designed for patients with RT in the past, now there many studies for these patients that incorporate new drugs and novel combinations that are being explored. In this review, we summarize the new information accumulated on RT with special emphasis on results involving the novel therapy tested for this entity, which represents an unmet clinical need.
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14
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Croizier C, Guièze R. [Richter Syndrome: Diagnostic and Therapeutic Management]. Bull Cancer 2021; 108:521-527. [PMID: 33896586 DOI: 10.1016/j.bulcan.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/12/2021] [Accepted: 01/18/2021] [Indexed: 10/21/2022]
Abstract
Richter syndrome (RS) is defined as the occurrence of an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL) and rarely Hodgkin lymphoma (HL), in a patient with prior or concomitant chronic lymphocytic leukemia (CLL). RS is estimated to occur in 0.5-1 % per year and is associated with adverse outcome. In the vast majority of patients (80 %), RS is clonally related to the prior CLL. Those with unrelated RS appear to have better outcome. The therapeutic approach is based on those of de novo DLBCL or HL. However, even with modern immunochemotherapy regimens, response rate remains low. In eligible patients with related RS, a consolidation by autologous or allogeneic stem-cell transplantation must be proposed. Combinations including therapies targeting BCR or BCL2 and effective in CLL are currently being evaluated in RS. Novels immunotherapies could be promising approaches based on preliminary results.
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Affiliation(s)
- Carolyne Croizier
- Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Estaing, 1, place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France.
| | - Romain Guièze
- Service d'Hématologie Clinique et de Thérapie Cellulaire, CHU Estaing, 1, place Lucie et Raymond Aubrac, 63000 Clermont-Ferrand, France; EA 7453, CHELTER, Université Clermont Auvergne, CHU Estaing, Hématologie Biologique, 1, place Lucie et Raymond Aubrac, 63003 Clermont-Ferrand, France
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15
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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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16
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Quinquenel A, Aurran-Schleinitz T, Clavert A, Cymbalista F, Dartigeas C, Davi F, de Guibert S, Delmer A, Dilhuydy MS, Feugier P, Fornecker LM, Ghez D, Guieze R, Laribi K, Leblond V, Leprêtre S, Letestu R, Lévy V, Nguyen-Khac F, Michallet AS, Tomowiak C, Tournilhac O, Ysebaert L, Troussard X. Diagnosis and Treatment of Chronic Lymphocytic Leukemia: Recommendations of the French CLL Study Group (FILO). Hemasphere 2020; 4:e473. [PMID: 33062946 PMCID: PMC7523785 DOI: 10.1097/hs9.0000000000000473] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/24/2020] [Indexed: 01/23/2023] Open
Abstract
As a result of significant recent developments, the management of patients with chronic lymphocytic leukemia (CLL) is changing, and new therapeutic options will continue to emerge in the near future. The recommendations of the French Innovative Leukemia Organization (FILO-CLL) group presented here are intended to provide practical recommendations for physicians taking care of CLL patients, taking into account the availability of both biological tests and therapies in daily practice in France at the time of publication. This text details the documented information and guidelines on diagnosis, indications for treatment, infectious complications and therapeutic strategies in frontline and relapsed CLL as well as in particular conditions such as autoimmune cytopenia or Richter syndrome.
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Affiliation(s)
- Anne Quinquenel
- Centre Hospitalier Universitaire (CHU) de Reims, Hôpital Robert Debré, Reims, France
- Université Reims Champagne-Ardenne, unité de Formation et de recherche (UFR) Médecine, Reims, France
| | | | | | - Florence Cymbalista
- Groupe des Hôpitaux Universitaires Paris Seine Saint-Denis (GHUPSSD), Assistance Publique Hôpitaux de Paris (AP-HP), Bobigny, France
- Unité Mixte de recherche (UMR) U978 INSERM, Bobigny, France
- Université Paris 13, UFR Santé Médecine Biologie Humaine (SMBH), Bobigny, France
| | | | - Frédéric Davi
- Sorbonne Université, Hôpital de la Pitié-Salpêtrière, AP-HP, Paris, France
| | | | - Alain Delmer
- Centre Hospitalier Universitaire (CHU) de Reims, Hôpital Robert Debré, Reims, France
- Université Reims Champagne-Ardenne, unité de Formation et de recherche (UFR) Médecine, Reims, France
| | | | | | - Luc-Matthieu Fornecker
- Institut de Cancerologie de Strasbourg Europe, Strasbourg, France
- INSERM S-113, Strasbourg, France
| | - David Ghez
- Institut Gustave Roussy, Villejuif, France
| | | | | | - Véronique Leblond
- Sorbonne Université, Hôpital de la Pitié-Salpêtrière, AP-HP, Paris, France
| | - Stéphane Leprêtre
- Inserm U1245 and Department of Hematology, Centre Henri Becquerel and Normandie Univ UNIROUEN, Rouen, France
| | - Rémi Letestu
- Groupe des Hôpitaux Universitaires Paris Seine Saint-Denis (GHUPSSD), Assistance Publique Hôpitaux de Paris (AP-HP), Bobigny, France
- Unité Mixte de recherche (UMR) U978 INSERM, Bobigny, France
- Université Paris 13, UFR Santé Médecine Biologie Humaine (SMBH), Bobigny, France
| | - Vincent Lévy
- Groupe des Hôpitaux Universitaires Paris Seine Saint-Denis (GHUPSSD), Assistance Publique Hôpitaux de Paris (AP-HP), Bobigny, France
- Université Paris 13, UFR Santé Médecine Biologie Humaine (SMBH), Bobigny, France
| | | | | | | | | | - Loïc Ysebaert
- Institut Universitaire du Cancer de Toulouse (IUCT) – Oncopole, Toulouse, France
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17
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Abrisqueta P, Delgado J, Alcoceba M, Oliveira AC, Loscertales J, Hernández‐Rivas JA, Ferrà C, Cordoba R, Yáñez L, Medina A, Motlló C, Iacoboni G, Villacampa G, González M, Bosch F. Clinical outcome and prognostic factors of patients with Richter syndrome: real‐world study of the Spanish Chronic Lymphocytic Leukemia Study Group (GELLC). Br J Haematol 2020; 190:854-863. [DOI: 10.1111/bjh.16748] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Pau Abrisqueta
- Department of Hematology Hospital Vall d'Hebron Barcelona Spain
| | - Julio Delgado
- Department of Hematology Hospital Clínic Barcelona Spain
| | - Miguel Alcoceba
- Department of Hematology University Hospital of Salamanca (HUS/IBSAL) CIBERONC and Center for Cancer Research‐IBMCC (USAL‐CSIC) Salamanca Spain
| | - Ana Carla Oliveira
- Department of Hematology Institut Català d'Oncologia, L'Hospitalet de LLobregat Hospitalet Spain
| | - Javier Loscertales
- Department of Hematology Hospital Universitario de La Princesa IIS‐IP Madrid Spain
| | | | - Christelle Ferrà
- Department of Hematology University Hospital GermansTrias y Pujol Badalona Spain
| | - Raul Cordoba
- Department of Hematology Fundación Jiménez Díaz Madrid Spain
| | - Lucrecia Yáñez
- Department of Hematology Hospital Marqués de Valdecilla Santander Spain
| | - Angeles Medina
- Department of Hematology Hospital Costa del Sol Marbella Spain
| | - Cristina Motlló
- Department of Hematology Hospital Sant Joan de Déu, Fundació Althaia Manresa Spain
| | - Gloria Iacoboni
- Department of Hematology Hospital Vall d'Hebron Barcelona Spain
| | - Guillermo Villacampa
- Oncology Data Science (OdysSey Group) Vall d’Hebron Institute of Oncology Barcelona Spain
| | - Marcos González
- Department of Hematology University Hospital of Salamanca (HUS/IBSAL) CIBERONC and Center for Cancer Research‐IBMCC (USAL‐CSIC) Salamanca Spain
| | - Francesc Bosch
- Department of Hematology Hospital Vall d'Hebron Barcelona Spain
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18
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Wang Y, Tschautscher MA, Rabe KG, Call TG, Leis JF, Kenderian SS, Kay NE, Muchtar E, Van Dyke DL, Koehler AB, Schwager SM, Slager SL, Parikh SA, Ding W. Clinical characteristics and outcomes of Richter transformation: experience of 204 patients from a single center. Haematologica 2019; 105:765-773. [PMID: 31197071 PMCID: PMC7049354 DOI: 10.3324/haematol.2019.224121] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/12/2019] [Indexed: 12/14/2022] Open
Abstract
The natural history, prognostication and optimal treatment of Richter transformation developed from chronic lymphocytic leukemia (CLL) are not well defined. We report the clinical characteristics and outcomes of a large series of biopsy-confirmed Richter transformation (diffuse large B-cell lymphoma or high grade B-cell lymphoma, n=204) cases diagnosed from 1993 to 2018. After a median follow up of 67.0 months, the median overall survival (OS) was 12.0 months. Patients who received no prior treatment for CLL had significantly better OS (median 46.3 vs. 7.8 months; P<0.001). Patients with elevated lactate dehydrogenase (median 6.2 vs. 39.9 months; P<0.0001) or TP53 disruption (median 8.3 vs. 12.8 months; P=0.046) had worse OS than those without. Immunoglobulin heavy chain variable region gene mutation, cell of origin, Myc/Bcl-2 double expression and MYC/BCL2/BCL6 double-/triple-hit status were not associated with OS. In multivariable Cox regression, elevated lactate dehydrogenase [Hazard ratio (HR) 2.3, 95% Confidence Interval (CI): 1.3-4.1; P=0.01], prior CLL treatment (HR 2.0, 95%CI: 1.2-3.5; P=0.01), and older age (HR 1.03, 95%CI: 1.01-1.05; P=0.01) were associated with worse OS. Twenty-four (12%) patients underwent stem cell transplant (20 autologous and 4 allogeneic), and had a median post-transplant survival of 55.4 months. In conclusion, the overall outcome of Richter transformation is poor. Richter transformation developed in patients with untreated CLL has significantly better survival. Stem cell transplant may benefit select patients.
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Affiliation(s)
- Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Kari G Rabe
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Jose F Leis
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ
| | | | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Daniel L Van Dyke
- Division of Laboratory Genetics and Genomics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Susan L Slager
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Wei Ding
- Division of Hematology, Mayo Clinic, Rochester, MN
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19
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Xia L, Wang Y, Li T, Hu X, Chen Q, Liu L, Jiang B, Li C, Wang H, Wang S, Yang G, Bao Y. The clinical study on treatment of CD19-directed chimeric antigen receptor-modified T cells in a case of refractory Richter syndrome. Cancer Med 2019; 8:2930-2941. [PMID: 31050207 PMCID: PMC6558585 DOI: 10.1002/cam4.2193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/17/2022] Open
Abstract
Richter syndrome (RS) indicates the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma (mostly DLBCL). Richter syndrome is a rare complication with an aggressive clinical course, bearing an unfavorable prognosis. Currently, there is no effective treatment for it. As a novel cellular‐based immune therapy, chimeric antigen receptor‐modified T (CART) cells treatment is gradually used in treating hematological malignancies, especially in CD19+ B‐cell malignancy. Therefore, CD19‐directed chimeric antigen receptor‐modified T cells (CART‐19) treatment is promising to be used as a new method for RS patients. In our study, one RS patient expressing high level of CD19 molecule was enrolled in clinical trial; he has received a series of treatments but did not achieve a satisfactory therapeutic effect. The patient totally received 3.55 × 108 autologous CART‐19 cells infusion. After CART‐19 infusion, the mainly clinical side effect was repeated fever. The maximal duration period was 24 days and the highest temperature was 40.1°C. Pancytopenia and significantly serum cytokines level rise were observed, including IFN‐γ, IL‐6, and IL‐10. Before discharge, the level of cytokines reduced to normal levels. In addition, we detected the serum biochemical indices as like K+, Ca2+, creatinine, and glutamic‐pyruvic transaminase, all of these indices were normal. This showed that there was no tumor necrosis syndrome after treatment. The proportion of B cells in patient's peripheral blood decreased from 72% to 40.2% after infusion, co‐occurring with reduction in lymph nodes and hematopoietic reconstitution. Based on the recent revolution in the therapeutic landscape for hematological malignancies including B‐cell lymphomas, CART‐CD19 cell therapy as a new therapeutic option for RS might be available in the coming years. It aims to reduce patient's tumor burden, prolong their survival time, and provide opportunities for other sequential therapy such as chemotherapy and bone marrow transplantation.
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Affiliation(s)
- Leiming Xia
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China.,Basic College of Medicine, Anhui Medical University, Hefei, China
| | - Yi Wang
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Tan Li
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Xueying Hu
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Qian Chen
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Liu Liu
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Beilei Jiang
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
| | - Caixin Li
- Shanghai Telebio Biomedical Co. Ltd., Hefei, China
| | - Hua Wang
- Shanghai Telebio Biomedical Co. Ltd., Hefei, China
| | - Siying Wang
- Basic College of Medicine, Anhui Medical University, Hefei, China
| | | | - Yangyi Bao
- Department of Hematology, The First People`s Hospital of Hefei, Hefei, China
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20
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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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21
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Ding W. Richter transformation in the era of novel agents. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:256-263. [PMID: 30504319 PMCID: PMC6245983 DOI: 10.1182/asheducation-2018.1.256] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Recent approvals of several oral targeted agents have revolutionized chronic lymphocytic leukemia (CLL) therapy. However, CLL patients continue to progress; particularly, 4% to 20% of previously treated CLL patients undergo transformation into high-grade lymphoma. Richter transformation is defined as a transformation of CLL into aggressive lymphoma, most commonly diffuse large B-cell lymphoma. These patients typically have poor response to traditional chemotherapy used to treat de novo diffuse large B-cell lymphoma and similar or shorter overall survival (median 3-11 months) in the era of novel agents. Here, I review the contemporary literature on Richter transformation, particularly in the context of novel agents used in CLL, and discuss the management approach for these patients.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Disease-Free Survival
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Survival Rate
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Affiliation(s)
- Wei Ding
- Chronic Lymphocytic Leukemia Group, Division of Hematology, Mayo Clinic, Rochester, MN
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22
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Godfrey J, Leukam MJ, Smith SM. An update in treating transformed lymphoma. Best Pract Res Clin Haematol 2018; 31:251-261. [PMID: 30213394 DOI: 10.1016/j.beha.2018.07.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
Indolent lymphomas typically have a prolonged course and favorable prognosis. Recent data support survival times that can reach several decades, even if periodic treatment is needed to manage symptoms or stabilize disease. However, all indolent lymphomas have the potential to undergo transformation to an aggressive phenotype, clinically characterized by a rapid progression of adenopathy, new-onset constitutional symptoms, or laboratory abnormalities, and the immediate need for therapeutic intervention. The most common scenario is transformation of follicular lymphoma to either diffuse large B-cell lymphoma or high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 translocations; however, other indolent subtypes such as marginal zone lymphoma, lymphoplasmacytic lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukemia, or even nodular lymphocyte predominant Hodgkin lymphoma, can undergo similar histologic transformation. The prognosis of transformed lymphomas has historically been quite poor, but there is ample evidence this is changing in the rituximab era. This article will provide a review of transformed lymphomas with an emphasis on treatment and the nuances of diagnosis and clinical management. Unless otherwise specified, all discussion in this review pertains to transformed follicular lymphoma which is the more common scenario and the subtype with the most robust data. In many cases, this information can be extrapolated and applied to other indolent histologies (i.e. transformed marginal zone lymphoma); however, several other clinical scenarios, such as Richter's transformation and "double hit" transformations, warrant a distinct discussion and will be reviewed separately.
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Affiliation(s)
- James Godfrey
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA
| | - Michael J Leukam
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA
| | - Sonali M Smith
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago, USA.
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23
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Abstract
AbstractRichter syndrome (RS) is the development of an aggressive lymphoma in patients with chronic lymphocytic leukemia (CLL). Two pathologic variants of RS are recognized: namely, the diffuse large B-cell lymphoma (DLBCL) variant and the rare Hodgkin lymphoma (HL) variant. Histologic documentation is mandatory to diagnose RS. The clinical suspicion of RS should be based on clinical signs and symptoms. Differential diagnosis between CLL progression and RS and choice of the biopsy site may take advantage of positron emission tomography/computed tomography. Molecular lesions of regulators of proliferation (CDKN2A, NOTCH1, MYC) and apoptosis (TP53) overall associate with ∼90% of DLBCL-type RS, whereas the biology of the HL-type RS is largely unknown. The prognosis of the DLBCL-type RS is unfavorable; the outcome of HL-type RS appears to be better. The most important RS prognostic factor is the clonal relationship between the CLL and the aggressive lymphoma clones, with clonally unrelated RS having a better prognosis. Rituximab-containing combination chemotherapy for DLBCL is the most widely used treatment in DLBCL-type RS. Fit patients who respond to induction therapy should be offered stem cell transplantation (SCT) to prolong survival. Adriamycin, bleomycin, vinblastine, and dacarbazine is the preferred regimen for the HL-type RS, and SCT consolidation is less used in this condition.
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Zemanova J, Hylse O, Collakova J, Vesely P, Oltova A, Borsky M, Zaprazna K, Kasparkova M, Janovska P, Verner J, Kohoutek J, Dzimkova M, Bryja V, Jaskova Z, Brychtova Y, Paruch K, Trbusek M. Chk1 inhibition significantly potentiates activity of nucleoside analogs in TP53-mutated B-lymphoid cells. Oncotarget 2018; 7:62091-62106. [PMID: 27556692 PMCID: PMC5308713 DOI: 10.18632/oncotarget.11388] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 08/08/2016] [Indexed: 12/13/2022] Open
Abstract
Treatment options for TP53-mutated lymphoid tumors are very limited. In experimental models, TP53-mutated lymphomas were sensitive to direct inhibition of checkpoint kinase 1 (Chk1), a pivotal regulator of replication. We initially tested the potential of the highly specific Chk1 inhibitor SCH900776 to synergize with nucleoside analogs (NAs) fludarabine, cytarabine and gemcitabine in cell lines derived from B-cell malignancies. In p53-proficient NALM-6 cells, SCH900776 added to NAs enhanced signaling towards Chk1 (pSer317/pSer345), effectively blocked Chk1 activation (Ser296 autophosphorylation), increased replication stress (p53 and γ-H2AX accumulation) and temporarily potentiated apoptosis. In p53-defective MEC-1 cell line representing adverse chronic lymphocytic leukemia (CLL), Chk1 inhibition together with NAs led to enhanced and sustained replication stress and significantly potentiated apoptosis. Altogether, among 17 tested cell lines SCH900776 sensitized four of them to all three NAs. Focusing further on MEC-1 and co-treatment of SCH900776 with fludarabine, we disclosed chromosome pulverization in cells undergoing aberrant mitoses. SCH900776 also increased the effect of fludarabine in a proportion of primary CLL samples treated with pro-proliferative stimuli, including those with TP53 disruption. Finally, we observed a fludarabine potentiation by SCH900776 in a T-cell leukemia 1 (TCL1)-driven mouse model of CLL. Collectively, we have substantiated the significant potential of Chk1 inhibition in B-lymphoid cells.
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Affiliation(s)
- Jana Zemanova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondrej Hylse
- Center of Biomolecular and Cellular Engineering, International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Chemistry, CZ Openscreen, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Jana Collakova
- Institute of Physical Engineering, Faculty of Mechanical Engineering, Brno University of Technology, Brno, Czech Republic.,CEITEC - Central European Institute of Technology, Brno University of Technology, Brno, Czech Republic
| | - Pavel Vesely
- CEITEC - Central European Institute of Technology, Brno University of Technology, Brno, Czech Republic
| | - Alexandra Oltova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Borsky
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Kristina Zaprazna
- CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Marie Kasparkova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pavlina Janovska
- Institute of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Jan Verner
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiri Kohoutek
- Department of Chemistry and Toxicology, Veterinary Research Institute, Brno, Czech Republic
| | - Marta Dzimkova
- Department of Chemistry and Toxicology, Veterinary Research Institute, Brno, Czech Republic
| | - Vitezslav Bryja
- Institute of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Cytokinetics, Institute of Biophysics, Academy of Sciences of the Czech Republic, Brno, Czech Republic
| | - Zuzana Jaskova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Yvona Brychtova
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Kamil Paruch
- Center of Biomolecular and Cellular Engineering, International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic.,Department of Chemistry, CZ Openscreen, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Martin Trbusek
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Abstract
The term Richter syndrome (RS) indicates the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma. RS is a rare complication with an aggressive clinical course, bearing an unfavorable prognosis. In the majority of cases, CLL transforms into RS as diffuse large B cell lymphoma (DLBCL), and a clonal relation between the two processes can be found. However, clonally unrelated RS can occur and transformations to other histologies beside DLBCL have been described. Recent data have shed some light on genetic characteristics that can influence and drive the transformation from CLL to RS. This molecular information has not been translated yet into significant treatment advances, and currently the therapy regimens for RS continue to rely on intensive chemotherapy combinations followed by stem cell transplant in suitable candidates. Based on the rapid pace of discoveries in the field of hematological malignancies and on the recent revolution in the therapeutic landscape for CLL and B cell lymphomas, new therapeutic options for RS might be available in the upcoming years.
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Affiliation(s)
- Candida Vitale
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Agbay RLMC, Jain N, Loghavi S, Medeiros LJ, Khoury JD. Histologic transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma. Am J Hematol 2016; 91:1036-43. [PMID: 27414262 DOI: 10.1002/ajh.24473] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 07/05/2016] [Accepted: 07/12/2016] [Indexed: 12/20/2022]
Abstract
Although generally considered a clinically indolent neoplasm, CLL/SLL may undergo transformation to a clinically aggressive lymphoma. The most common form of transformation, to DLBCL, is also known as Richter syndrome. Transformation determines the course of the disease and is associated with unfavorable patient outcome. Precise detection of transformation and identification of predictive biomarkers and specific molecular pathways implicated in the pathobiology of transformation in CLL/SLL will enable personalized therapeutic approach and provide potential avenues for improving the clinical outcome of patients. In this review, we present an overview of the pathologic features, risk factors, and pathogenic mechanisms of CLL/SLL transformation. Am. J. Hematol. 91:1036-1043, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Rose Lou Marie C. Agbay
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Nitin Jain
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Sanam Loghavi
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - L. Jeffrey Medeiros
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Joseph D. Khoury
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
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van Gelder M, van Oers MH, Alemayehu WG, Abrahamse-Testroote MCJ, Cornelissen JJ, Chamuleau ME, Zachée P, Hoogendoorn M, Nijland M, Petersen EJ, Beeker A, Timmers GJ, Verdonck L, Westerman M, de Weerdt O, Kater AP. Efficacy of cisplatin-based immunochemotherapy plus alloSCT in high-risk chronic lymphocytic leukemia: final results of a prospective multicenter phase 2 HOVON study. Bone Marrow Transplant 2016; 51:799-806. [DOI: 10.1038/bmt.2016.9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/22/2015] [Accepted: 12/31/2015] [Indexed: 12/21/2022]
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