Rapid and complete response to idelalisib in a case of Richter syndrome

From genetics to therapy: Unraveling the complexities of Richter transformation in chronic lymphocytic leukemia

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.

Richter Transformation of Chronic Lymphocytic Leukemia-Are We Making Progress?

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.

Long-term effect of venetoclax therapy in a patient with the transformation of chronic lymphocytic leukemia into Richter's syndrome

Richter's syndrome (RS) is the next step in the progression of chronic lymphocytic leukemia (CLL) progression. It leads to reduced overall patient survival, the necessity of aggressive chemotherapy and a decline in the quality of life. The first line of RS treatment includes traditional chemotherapy such as rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone. However, during the past decade, novel targeted agents added to the therapy dramatically changed the treatment outcome for patients with RS. In our case, we describe a patient with CLL that had progressed to RS and achieved complete remission that lasted > 15 months with venetoclax monotherapy.

Novel Approaches for the Treatment of Patients with Richter's Syndrome

In the last 10–15 years, the way to treat cancers has dramatically changed towards precision medicine approaches. These treatment options are mainly based on selective targeting against signaling pathways critical for or detrimentally activated in cancer cells in cancer cells, as well as exploiting molecules that are specifically expressed on neoplastic cells, also known as tumor-associated antigens. These considerations hold true also in the hematological field where a plethora of novel targeted agents have reached patients’ bedside, significantly improving clinical responses. Chronic lymphocytic leukemia (CLL) is an example of how targeted therapies, such as BTK, PI3K, or Bcl-2 inhibitors as well as anti-CD20 antibodies, have improved patients’ management, even when adopted as frontline treatment. However, these advancements do not apply to Richter’s syndrome (RS), the transformation of CLL into a very aggressive and fatal lymphoma, occurring in 2–10% of patients. RS is usually a fast-growing lymphoma of the diffuse large B cell or the Hodgkin’s variant, with a dismal prognosis. Despite advancements in depicting and understanding the genetic background of RS and its pathogenesis, no significant clinical results have been registered. In the last couple of years, several studies have started to investigate the impact of novel drugs or drug combinations and some of them have opened for clinical trials, currently in phase I or II, whose results will be soon available. This review will present an overview of current and most recent therapeutic options in RS, discussing also how results coming from xenograft models may help in designing and identifying novel treatment opportunities to overcome the lack of effective therapies.

Pathology of Seminoma Coinciding With Small Lymphocytic Lymphoma/Chronic Lymphocytic Leukemia

We present the case of a 71-year-old male with an incidental diagnosis of seminoma coinciding with small lymphocytic lymphoma/chronic lymphocytic leukemia in the retroperitoneum. This case report illustrates the cytology, histology, immunohistochemistry, flow cytometry, and fluorescence in situ hybridization features of this exceptional case and sheds light on the importance of a collaborative multidisciplinary team in delivering quality patient care. 

Approved and emerging PI3K inhibitors for the treatment of chronic lymphocytic leukemia and non-Hodgkin lymphoma

INTRODUCTION

PI3K inhibition with idelalisib (at that time CAL-101) was at the forefront of the development of molecularly targeted therapies in Chronic Lymphocytic Leukemia (CLL)/Small Lymphocytic Leukemia (SLL) and follicular lymphoma. However, after initial approval, subsequent trials identified specific immune-mediated and infectious toxicity that led to a reduced use and stopped the further development of this agent. PI3K inhibition as a treatment paradigm fell out of favor compared to other developments such as BTK or BCL2 inhibitors.

AREAS COVERED

This review provides an overview of the experience with approved PI3Ki, including long-term experience, and highlights the current PI3Ki developments in CLL, B-cell and T-Cell Non-Hodgkin's Lymphoma.

EXPERT OPINION

With careful monitoring and prophylaxis usage of the first-generation PI3K inhibitor, idelalisib, in the approved indications, it is safe and remains an option in higher line therapy after the failure of other novel agents and/or chemoimmunotherapy. New developments with next-generation PI3K inhibitors of improved tolerability and sustained efficacy reignited the treatment principle and already led to newly approved therapeutic options for patients. Certainly, the authors here believe that PI3K inhibitors as a monotherapy and in combination with other agents is currently a rapidly evolving field in cancer treatment.