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Yiğit Kaya S, Mutlu YG, Malkan ÜY, Mehtap Ö, Keklik Karadağ F, Korkmaz G, Elverdi T, Saydam G, Özet G, Ar MC, Melek E, Maral S, Kaynar L, Sevindik ÖG. Single agent vemurafenib or rituximab-vemurafenib combination for the treatment of relapsed/refractory hairy cell leukemia, a multicenter experience. Leuk Res 2024; 140:107495. [PMID: 38599153 DOI: 10.1016/j.leukres.2024.107495] [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: 01/26/2024] [Revised: 03/07/2024] [Accepted: 03/21/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Hairy cell leukemia (HCL) is a rare mature B-cell malignancy that is primarily treated with purine analogues. However, relapse remains a significant challenge, prompting the search for alternative therapies. The BRAF V600E mutation prevalent in HCL patients provides a target for treatment with vemurafenib. PATIENTS AND METHODS This multicenter retrospective study included nine patients with relapsed/refractory (R/R) HCL from six different centers. Patient data included demographics, prior treatments, clinical outcomes, and adverse events. RESULTS Patients received different treatment regimens between centers, including vemurafenib alone or in combination with rituximab. Despite the differences in protocols, all patients achieved at least a partial response, with seven patients achieving a complete response. Adverse events were generally mild with manageable side effects. The absence of myelotoxic effects and manageable side effects make BRAF inhibitors attractive, especially for patients ineligible for purine analogues or those with severe neutropenia. CONCLUSION Single agent vemurafenib or in combination with rituximab appears to be a promising therapeutic option for R/R HCL. Further research is needed to establish standardized treatment protocols and to investigate long-term outcomes.
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Affiliation(s)
- Süreyya Yiğit Kaya
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Turkey.
| | - Yaşa Gül Mutlu
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Ümit Yavuz Malkan
- Department of Hematology, Faculty of Medicine, Hacettepe University, Turkey
| | - Özgür Mehtap
- Department of Hematology, Faculty of Medicine, Kocaeli University, Turkey
| | | | - Gülten Korkmaz
- Department of Hematology, Ankara Bilkent City Hospital, Turkey
| | - Tuğrul Elverdi
- Department of Hematology, Cerrahpaşa Faculty of Medicine, Istanbul University, Turkey
| | - Güray Saydam
- Department of Hematology, Faculty of Medicine, Ege University, Turkey
| | - Gülsüm Özet
- Department of Hematology, Ankara Bilkent City Hospital, Turkey
| | - Muhlis Cem Ar
- Department of Hematology, Cerrahpaşa Faculty of Medicine, Istanbul University, Turkey
| | - Elif Melek
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Senem Maral
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Leylagül Kaynar
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Ömür Gökmen Sevindik
- Department of Hematology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey
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Troussard X, Maître E, Paillassa J. Hairy cell leukemia 2024: Update on diagnosis, risk-stratification, and treatment-Annual updates in hematological malignancies. Am J Hematol 2024; 99:679-696. [PMID: 38440808 DOI: 10.1002/ajh.27240] [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: 12/20/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 03/06/2024]
Abstract
DISEASE OVERVIEW Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogenous group of mature lymphoid B-cell disorders characterized by the identification of hairy cells, a specific genetic profile, a different clinical course and the need for appropriate treatment. DIAGNOSIS Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of 3 or 4 based on the CD11c, CD103, CD123, and CD25 expression, the trephine biopsy which makes it possible to specify the degree of tumoral bone marrow infiltration and the presence of BRAFV600E somatic mutation. RISK STRATIFICATION Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood, and the immunoglobulin heavy chain variable region gene mutational status. VH4-34 positive HCL cases are associated with a poor prognosis, as well as HCL with TP53 mutations and HCL-V. TREATMENT Patients should be treated only if HCL is symptomatic. Chemotherapy with risk-adapted therapy purine analogs (PNAs) are indicated in first-line HCL patients. The use of chemo-immunotherapy combining cladribine (CDA) and rituximab (R) represents an increasingly used therapeutic approach. Management of relapsed/refractory disease is based on the use of BRAF inhibitors (BRAFi) plus R, MEK inhibitors (MEKi), recombinant immunoconjugates targeting CD22, Bruton tyrosine kinase inhibitors (BTKi), and Bcl-2 inhibitors (Bcl-2i). However, the optimal sequence of the different treatments remains to be determined.
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Affiliation(s)
| | - Elsa Maître
- Laboratoire Hématologie, CHU Côte de Nacre, Caen Cedex, France
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Soong D, Taylor J. New Targeted Therapy Combination Holds Promise to Untangle Hairy Cell Leukemia. NEJM EVIDENCE 2023; 2:EVIDe2300173. [PMID: 38320184 DOI: 10.1056/evide2300173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Hairy cell leukemia (HCL) is an uncommon B-cell neoplasm uniquely characterized by a high prevalence of the BRAFV600E mutation, which leads to constitutive activation of the mitogen-activated protein kinase (MAPK) pathway.1 In fact, the BRAFV600E point mutation is identified in nearly all cases of HCL; however, it is absent in HCL variant (vHCL) and rare in other B-cell neoplasms.2,3 Notably, in contrast to melanoma or other BRAF mutant solid tumors, HCL exhibits very few other mutations, potentially explaining the high response rates observed in patients treated with mutant BRAF-targeted agents, such as vemurafenib.
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Affiliation(s)
- Deborah Soong
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine, Miami
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Park JH, Devlin S, Durham BH, Winer ES, Huntington S, von Keudell G, Vemuri S, Shukla M, Falco V, Cuello B, Gore S, Stone R, Abdel-Wahab O, Tallman MS. Vemurafenib and Obinutuzumab as Frontline Therapy for Hairy Cell Leukemia. NEJM EVIDENCE 2023; 2:EVIDoa2300074. [PMID: 38320179 PMCID: PMC11110928 DOI: 10.1056/evidoa2300074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Hairy cell leukemia (HCL) is characterized by the underlying genetic lesion of BRAFV600E and responsiveness to BRAF inhibitors. We assessed the safety and activity of the BRAF inhibitor vemurafenib combined with obinutuzumab in patients with previously untreated HCL. METHODS: We conducted a single-arm, multicenter clinical study of vemurafenib plus obinutuzumab. Vemurafenib 960 mg twice daily was administered for four cycles, and obinutuzumab was administered in cycles 2 to 4. The primary end point was complete remission (CR). Secondary end points included assessment of safety, minimal residual disease (MRD), and BRAF allele burden according to digital droplet polymerase chain reaction (ddPCR). RESULTS: Thirty patients were enrolled in the study, and 27 patients completed all four cycles of treatments and achieved CR (90%; 95% confidence interval [CI], 73 to 98). Three patients discontinued the study early because of adverse events and were not evaluable for response. Of the 27 patients who achieved CR, 26 patients (96%; 95% CI, 81 to 99) achieved MRD negativity. BRAFV600E allele was undetectable by ddPCR in all 21 evaluable patients. At a median follow-up of 34.9 months (95% CI, 29.6 to 36.9), no patient experienced disease relapse. The most common vemurafenib-related adverse events were rash and arthralgia. Febrile neutropenia occurred in two patients, and blood or platelet transfusions were required in two patients. CONCLUSIONS: Combined time-limited vemurafenib and obinutuzumab achieved CR in more than 90% of patients with previously untreated HCL. In this small study, acquired vemurafenib resistance or dose-limiting toxicity was not observed. Patients were not observed long enough to reveal secondary malignancies. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT03410875.)
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Affiliation(s)
- Jae H Park
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Department of Medicine, Weill Cornell Medicine, New York
| | - Sean Devlin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York
| | - Benjamin H Durham
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Eric S Winer
- Leukemia Service, Department of Medicine, Dana-Farber Cancer Institute, Boston
| | | | | | - Shreya Vemuri
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Madhulika Shukla
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Victoria Falco
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Bernadette Cuello
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
| | - Steven Gore
- Yale Cancer Center, New Haven, CT
- National Cancer Institute, Bethesda, MD
| | - Richard Stone
- Leukemia Service, Department of Medicine, Dana-Farber Cancer Institute, Boston
| | - Omar Abdel-Wahab
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Molecular Pharmacology Program, Sloan Kettering Institute, New York
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York
- Department of Medicine, Northwestern Comprehensive Cancer Center, Chicago
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago
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Robak T, Robak P. Refractory and relapsed hairy-cell leukemia (HCL): casting light on promising experimental drugs in clinical trials. Expert Opin Investig Drugs 2023; 32:311-324. [PMID: 36931901 DOI: 10.1080/13543784.2023.2193323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Hairy cell leukemia (HCL) is a rare subtype of indolent lymphoid leukemia originating from a mature B lymphocyte. The standard first-line treatment for classic HCL, and HCL variant (HCLv), consists of purine nucleoside analogs (PNA), with or without rituximab. However, almost half of patients relapse and require subsequent therapy. AREAS COVERED This article summarizes recent achievements in the treatment of relapsed and refractory HCL. A literature search was conducted of the PubMed and MEDLINE database for articles in English. Publications from 2010 through January 2023 were scrutinized. The search terms used were hairy cell leukemia in conjunction with BRAF inhibitors, Bruton's tyrosine kinase (BTK) inhibitors, CD20 monoclonal antibodies, relapsed, refractory and variant.The growing understanding of HCL biology has allowed the design of several new, chemotherapy-free targeted drugs which have demonstrated encouraging efficacy in early clinical trials. EXPERT OPINION Novel drugs will soon be available to assist standard therapy for HCL and HCLv among patients with suboptimal results following PNA treatment. In particular, the BRAF inhibitors vemurafenib and dabrafenib, with or without rituximab, have revolutionized treatment of patients with relapsed or refractory disease.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Łódź, Poland
- Department of General Hematology, Copernicus Memorial Hospital, Lodz, Poland
| | - Paweł Robak
- Department of Experimental Hematology, Medical University of Lodz, Lodz, Poland
- Department of Hematooncology, Copernicus Memorial Hospital, Lodz, Poland
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Gargiulo E, Giordano M, Niemann CU, Moussay E, Paggetti J, Morande PE. The protective role of the microenvironment in hairy cell leukemia treatment: Facts and perspectives. Front Oncol 2023; 13:1122699. [PMID: 36968995 PMCID: PMC10031020 DOI: 10.3389/fonc.2023.1122699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023] Open
Abstract
Hairy cell leukemia (HCL) is an incurable, rare lymphoproliferative hematological malignancy of mature B cAlthough first line therapy with purine analogues leads to positive results, almost half of HCL patients relapse after 5-10 years, and standard treatment may not be an option due to intolerance or refractoriness. Proliferation and survival of HCL cells is regulated by surrounding accessory cells and soluble signals present in the tumor microenvironment, which actively contributes to disease progression. In vitro studies show that different therapeutic approaches tested in HCL impact the tumor microenvironment, and that this milieu offers a protection affecting treatment efficacy. Herein we explore the effects of the tumor microenvironment to different approved and experimental therapeutic options for HCL. Dissecting the complex interactions between leukemia cells and their milieu will be essential to develop new targeted therapies for HCL patients.
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Affiliation(s)
- Ernesto Gargiulo
- Tumor Stroma Interactions – Department of Cancer Research, Luxembourg Institute of HealthLuxembourg, Luxembourg
- Chronic Lymphocytic Leukemia Laboratory, Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- PERSIMUNE, Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Mirta Giordano
- Instituto de Medicina Experimental (IMEX)-CONICET, Academia Nacional de Medicina, Buenos Aires, Argentina
| | - Carsten U. Niemann
- Chronic Lymphocytic Leukemia Laboratory, Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Etienne Moussay
- Tumor Stroma Interactions – Department of Cancer Research, Luxembourg Institute of HealthLuxembourg, Luxembourg
- *Correspondence: Pablo Elías Morande, ; ; Etienne Moussay, ; Jérôme Paggetti,
| | - Jérôme Paggetti
- Tumor Stroma Interactions – Department of Cancer Research, Luxembourg Institute of HealthLuxembourg, Luxembourg
- *Correspondence: Pablo Elías Morande, ; ; Etienne Moussay, ; Jérôme Paggetti,
| | - Pablo Elías Morande
- Tumor Stroma Interactions – Department of Cancer Research, Luxembourg Institute of HealthLuxembourg, Luxembourg
- Instituto de Medicina Experimental (IMEX)-CONICET, Academia Nacional de Medicina, Buenos Aires, Argentina
- *Correspondence: Pablo Elías Morande, ; ; Etienne Moussay, ; Jérôme Paggetti,
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It's a BRAF new world for hairy cell leukemia. Blood 2022; 140:2649-2650. [PMID: 36548021 DOI: 10.1182/blood.2022017939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Maitre E, Paillassa J, Troussard X. Novel targeted treatments in hairy cell leukemia and other hairy cell-like disorders. Front Oncol 2022; 12:1068981. [PMID: 36620555 PMCID: PMC9815161 DOI: 10.3389/fonc.2022.1068981] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the category of mature B-cell neoplasms, splenic B-cell lymphoma and leukemia were clearly identified and include four distinct entities: hairy cell leukemia (HCL), splenic marginal zone lymphoma (SMZL), splenic diffuse red pulp lymphoma (SDRPL) and the new entity named splenic B-cell lymphoma/leukemia with prominent nucleoli (SBLPN). The BRAFV600E mutation is detected in nearly all HCL cases and offers a possibility of targeted therapy. BRAF inhibitors (BRAFi) represent effective and promising therapeutic approaches in patients with relapsed/refractory HCL. Vemurafenib and dabrafenib were assessed in clinical trials. The BRAFV600E mutation is missing in SDRPL and SBLPN: mitogen-activated protein kinase 1 (MAP2K1) mutations were found in 40% of SBLPN and VH4-34+ HCL patients, making possible to use MEK inhibitors (MEKi) such as trametinib, cobimetinib or binimetinib in monotherapy or associated with BRAFi. Other mutations may be associated and other signaling pathways involved, including the B-cell receptor signaling (BCR), cell cycle, epigenetic regulation and/or chromatin remodeling. In SDRPL, cyclin D3 (CCND3) mutations were found in 24% of patients, offering the possibility of using cell cycle inhibitors. Even if new emerging drugs, particularly those involved in the epigenetic regulation, have recently been added to the therapeutic armamentarium in HCL and HCL-like disorders, purine nucleoside analogs more and more associated with anti-CD20 monoclonal antibodies, are still used in the frontline setting. Thanks to the recent discoveries in genetics and signaling pathways in HCL and HCL-like disorders, new targeted therapies have been developed, have proven their efficacy and safety in several clinical trials and become essential in real life: BRAFi, MEKi, Bruton Tyrosine Kinase inhibitors (BTKi) and anti-CD22 immunotoxins. New other drugs emerged and have to be assessed in the future. In this article, we will discuss the main mutations identified in HCL and HCL-like disorders and the signaling pathways potentially involved in the pathogenesis of the different hairy cell disorders. We will discuss the results of the recent clinical trials, which will help us to propose an algorithm useful in clinical practice and we will highlight the different new drugs that may be used in the near future.
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Affiliation(s)
- Elsa Maitre
- Hématologie, Centre Hospitalier Universitaire Caen Normandie, Avenue Côte de Nacre, Caen, France
| | - Jerome Paillassa
- Service des Maladies du Sang, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Xavier Troussard
- Hématologie, Centre Hospitalier Universitaire Caen Normandie, Avenue Côte de Nacre, Caen, France,*Correspondence: Xavier Troussard,
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