Bendamustine and its role in the treatment of unfit patients with chronic lymphocytic leukaemia: a perspective review

With a median age of 72 years at first diagnosis, chronic lymphocytic leukaemia (CLL) is a disease of the elderly. At this age, many patients cannot bear an intensive chemoimmunotherapy like fludarabine, cyclophosphamide and rituximab (FCR), and therapeutic decisions are commonly complicated by a high burden of accompanying comorbidities. Clinical trials, on the other hand, are mostly designed to include a far healthier and younger trial population, with a median age in most studies well below 70 years, leading to an insufficient reflection of clinical reality. With the introduction of new targeted therapies, treatment of CLL is currently undergoing a profound change. New compounds like ibrutinib or idelalisib have enlarged the therapeutic options in treating CLL. However, so far, these oral medications imply continuous intake by the patient, which will at some point lead to the issue of adherence in most patients. In addition, long-term experiences are largely missing. In this setting, one of the oldest chemoactive substances remains a viable option for many CLL patients and their treating physicians: bendamustine, a nitrogen-mustard derivative, has proven to be a safe and efficient agent for treatment of CLL in the first- and second-line setting. In particular, there is some evidence that the substance is relatively well tolerated in elderly and unfit patients. In this review, we summarize the current data on bendamustine in the treatment of elderly and unfit patients with CLL and aim to provide a concise analysis and outlook on the current and future role of this substance in the era of new targeted agents.

'Use it again!': retherapy with bendamustine in indolent B-cell lymphoproliferative disorders

A pattern of relapse followed by further therapy is prevalent in patients with indolent lymphoid malignancies indicating the need for additional effective salvage therapies. Previous therapy, response and duration of response to that therapy are among the most important factors in determining the next therapy. Bendamustine, a bifunctional alkylating agent, has been tested alone or in combination in patients with chronic lymphocytic leukemia and indolent non-Hodgkin's lymphomas. In this article, the authors reported data, collected retrospectively, regarding repeatedly treating patients affected by indolent lymphoid malignancies with bendamustine-including regimens at the moment of relapse. Their experience showed that this drug is effective and manageable even when reused in both settings: chronic lymphocytic leukemia and non-Hodgkin's lymphomas combined with rituximab and/or mitoxantrone. The slow evolution in the treatment of patients with lymphoid malignancies has recently given way to a major revolution. Over the past decade, the availability of novel and active targeted agents, particularly monoclonal antibodies, has engendered major progress in the treatment of both aggressive and indolent lymphoid malignancies. Despite the fact that new therapeutic strategies are relying less on nonspecific cytotoxic drugs and more on targeted agents, a pattern of relapse followed by further therapy is prevalent in patients with indolent lymphoid malignancies, indicating the need for additional effective salvage therapies.

[Conventional therapeutic strategies for relapsed chronic lymphocytic leukemia]

The choice of salvage therapy for patients presenting relapsed chronic lymphocytic leukemia (CLL) has to take into account some factors influencing tumor resistance and comorbidities. Since 2010, new drugs targeting the tumor cells' signaling have been proposed for CLL patients. Waiting the results of various clinical trials evaluating these treatments, there is a need to describe the state-of-the-art concerning approved treatments such as chemotherapy and monoclonal antibodies.

Retreatment with bendamustine-containing regimens in patients with relapsed/refractory chronic lymphocytic leukemia and indolent B-cell lymphomas achieves high response rates and some long lasting remissions

Bendamustine and bendamustine/rituximab combinations have shown high efficacy in relapsed/refractory chronic lymphocytic leukemia (CLL) and indolent B-cell malignancies (non-Hodgkin lymphoma, NHL). No data exist about bendamustine retreatment after relapse, concerning efficacy and toxicity in this patient population. Eighty-eight outpatients (57 patients with CLL, 31 patients with NHL) who had previously been treated with bendamustine were retreated with a bendamustine regimen. Treatment consisted of bendamustine (B) or bendamustine + mitoxantrone (BM) or bendamustine + rituximab (BR) or bendamustine + mitoxantrone + rituximab (BMR). Median age was 72 years (50-88). A reversible grade 3 or 4 leukocytopenia or thrombocytopenia was observed in 24% and 13%, respectively. The overall response rate (ORR) was 76% (7% complete remission [CR], 69% partial remission [PR]) with 77% (6% CR, 71% PR) in CLL and 71% (8% CR, 63% PR) in NHL. ORR according to regimen was as follows: B: 57% (14% CR, 43% PR), BM: 70% (4% CR, 66% PR), BR: 55% (10% CR, 45% PR), BMR: 84% (7% CR, 78% PR). Bendamustine retreatment is feasible and achieves high response rates and some long lasting remissions.