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Pham N, Coombs CC, O'Brien S. Are we closer to a standard of care for Richter's syndrome? Novel treatments on the horizon. Expert Rev Hematol 2024; 17:117-126. [PMID: 38693662 DOI: 10.1080/17474086.2024.2350528] [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: 12/06/2023] [Accepted: 04/29/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION The therapeutic landscape for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) has significantly evolved over the past decade with dramatically improved outcomes with the introduction of targeted therapies. This unfortunately has not been the case for Richter transformation (RT), the histologic transformation to a more aggressive lymphoma, most typically diffuse large B-cell lymphoma (DLBCL). As such, RT continues to be one of the most challenging complications of CLL/SLL. Historically, RT has a poor response to treatment, with a minority reaching complete remission (CR) and overall survival (OS) being less than a year. AREAS COVERED The focus of this review is to discuss the effectiveness of commonly used regimens, and review existing data for emerging regimens being examined in ongoing clinical trials to improve prognosis and outcomes in patients with RT. Despite extensive efforts to optimize therapies for RT, there is still no generalized consensus on either first-line treatment regimens or regimens in the relapsed/refractory setting. RT continues to carry a high mortality rate without durable response to current therapeutic agents. EXPERT OPINION Ongoing and future research may identify novel treatment approaches that will eventually improve outcomes for patients with RT. The optimal care for RT patients is a clinical trial, when feasible.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Lymphoma, Large B-Cell, Diffuse/therapy
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/mortality
- Standard of Care
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Clinical Trials as Topic
- Molecular Targeted Therapy
- Treatment Outcome
- Disease Management
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Affiliation(s)
- Nghia Pham
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Catherine C Coombs
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
| | - Susan O'Brien
- Department of Medicine, Division of Hematology and Oncology at University of California, Irvine, USA
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2
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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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Briski R, Taylor J. Treatment of Richter Transformation of Chronic Lymphocytic Leukemia in the Modern Era. Cancers (Basel) 2023; 15:cancers15061857. [PMID: 36980742 PMCID: PMC10047346 DOI: 10.3390/cancers15061857] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Richter Transformation (RT) refers to the development of an aggressive lymphoma in the setting of chronic lymphocytic leukemia (CLL). While many variants of RT are recognized, diffuse large B-cell lymphoma (RT-DLBCL) is the most common (80%), followed by Hodgkin’s lymphoma (RT-HL, 19%). Diagnosis is based upon histologic evaluation of clinically suspicious lymph nodes. Positron emission tomography (PET) may be used to select the node of interest for biopsy. Although clonality testing is not a prerequisite of RT diagnosis, it has significant implications for survival. Clonally related DLBCL carries the worst prognosis with a median overall survival (OS) of less than one year in the era of combination chemotherapies with or without anti-CD20 antibodies. Prognosis has improved with the use of stem cell transplant and newer agents such as targeted therapy and newer forms of immunotherapy. Consideration of a clinical trial is encouraged. This review describes our current understanding of RT and focuses on treatment of RT-DLBCL, including clinical trials in progress and new therapies in development. We also report an illustrative example of a patient with clonally related DLBCL who survived two years after diagnosis without the use of combination chemotherapy.
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Affiliation(s)
- Robert Briski
- M.D. Anderson Cancer Center, Houston, TX 77030, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL 33136, USA
- Correspondence:
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Maier J, Lechel A, Marienfeld R, Barth TFE, Möller P, Mellert K. CARD9 Forms an Alternative CBM Complex in Richter Syndrome. Cancers (Basel) 2022; 14:cancers14030531. [PMID: 35158799 PMCID: PMC8833648 DOI: 10.3390/cancers14030531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/13/2022] [Accepted: 01/18/2022] [Indexed: 11/18/2022] Open
Abstract
Simple Summary The transformation process of chronic lymphocytic leukemia into an aggressive lymphoma, called Richter syndrome (RS), is incompletely understood, and therapeutic options are limited. Here, we report CARD9 to be expressed in a subset of RS tissue specimen and in the first and only available RS cell line, U-RT1. In U-RT1, CARD9 attaches to BCL10 and MALT1, and knockdown of CARD9 leads to a significant reduction in cell viability. We hypothesized that CARD9 plays an oncogenic role in RS through the activation of NF-κB signaling. Our findings may help to extend the current knowledge about the pathogenesis of RS and promote the development of targeted therapies for this aggressive disease. Abstract Richter syndrome (RS) is defined as the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma, mostly diffuse large B-cell lymphoma (DLBCL). Despite intensive therapy, patients with RS have an unfavorable clinical outcome. The detailed pathobiology of Richter transformation still needs to be elucidated. Here, we report high mRNA and protein levels of CARD9 in the RS cell line U-RT1. Co-immunoprecipitation revealed the assembly of a CBM complex using CARD9 instead of CARD11. CARD9 is known to be an activator of NF-кB signaling in myeloid cells. U-RT1 Western blot analyses showed phosphorylation of IκB as well as IKK, indicating a constitutively active canonical NF-кB pathway. This was further supported by the significant reduction in cell viability and CYLD cleavage products after CARD9 siRNA knockdown. We also showed immunostaining for CARD9 in 53% of cases analyzed in a series of RS tissue specimens, whereas other lymphomas rarely show CARD9 expression. This is the first report on ectopic expression and function of CARD9 in an aggressive B-cell lymphoma. Our findings suggest that CARD9 may contribute to the pathogenesis of RS.
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Affiliation(s)
- Julia Maier
- Institute of Pathology, University Hospital Ulm, 89081 Ulm, Germany; (J.M.); (R.M.); (T.F.E.B.); (K.M.)
| | - André Lechel
- Department of Internal Medicine I, University of Ulm, 89081 Ulm, Germany;
| | - Ralf Marienfeld
- Institute of Pathology, University Hospital Ulm, 89081 Ulm, Germany; (J.M.); (R.M.); (T.F.E.B.); (K.M.)
| | - Thomas F. E. Barth
- Institute of Pathology, University Hospital Ulm, 89081 Ulm, Germany; (J.M.); (R.M.); (T.F.E.B.); (K.M.)
| | - Peter Möller
- Institute of Pathology, University Hospital Ulm, 89081 Ulm, Germany; (J.M.); (R.M.); (T.F.E.B.); (K.M.)
- Correspondence:
| | - Kevin Mellert
- Institute of Pathology, University Hospital Ulm, 89081 Ulm, Germany; (J.M.); (R.M.); (T.F.E.B.); (K.M.)
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Paduri S, Nandu NS, Brucker T, Roach P, Pant-Purohit M. Unique case of atraumatic splenic rupture in a patient with chronic lymphocytic leukaemia with Richter's transformation. BMJ Case Rep 2021; 14:e242193. [PMID: 34670746 PMCID: PMC8529982 DOI: 10.1136/bcr-2021-242193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2021] [Indexed: 01/21/2023] Open
Abstract
Though rare, atraumatic rupture of the spleen can be a complication in certain leukaemias and lymphomas. We present a unique case of atraumatic rupture of the spleen in a patient with chronic lymphocytic leukaemia. The patient presented to the emergency department with abdominal pain; he had been on ibrutinib therapy but stopped taking the medication abruptly 6 days prior. On evaluation, he was found to have a ruptured spleen with a haemoperitoneum. Pathology of the excised spleen showed infiltration of the spleen with hyperproliferated CD5+ intermediate-to-large cells, consistent with B-cell lymphoma and favouring Richter's transformation. There are only a few available reports of patients with similar presentations identified in our literature review.
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Affiliation(s)
- Swetha Paduri
- Internal Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Nitish Singh Nandu
- Internal Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Thomas Brucker
- Department of Pathology and Laboratory, Anatomic and Clinical Pathologist, Medical Director of Flow Cytometry Laboratory,Medical Director, department of Anatomic Pathology, Department of Pathology and Laboratory Medicine, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
| | - Paul Roach
- General & Oncologic Surgery, Lovell FHCC Department of Surgery, North Chicago, Illinois, USA
| | - Mukta Pant-Purohit
- Hemtology/Oncology, Section Chief, Hemtology/Oncology Captain James A Lovell Federal Health Care Center, Assistant Professor, Rosalind Franklin University, North Chicago, Illinois, USA
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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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7
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The Occurrence of Richter’s Syndrome during Treatment with Obinutuzumab and Chlorambucil. Case Rep Hematol 2020; 2020:8363427. [PMID: 32724682 PMCID: PMC7381955 DOI: 10.1155/2020/8363427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/09/2019] [Accepted: 06/03/2020] [Indexed: 12/05/2022] Open
Abstract
Chronic lymphocytic leukaemia is a slow-growing leukaemia of developing B-lymphocytes, which may transform to an aggressive lymphoma known as Richter's syndrome. While Richter's syndrome can present in untreated or relapsed-refractory cases, it may occur upon the commencement of less intensity treatment regimens. We present a case of Richter's syndrome following treatment with chlorambucil and obinutuzumab and review of available literature on the topic.
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8
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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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Lenartova A, Randen U, Johannesen TB, Tjønnfjord GE. Richter syndrome epidemiology in a large population based chronic lymphocytic leukemia cohort from Norway. Cancer Epidemiol 2019; 60:128-133. [DOI: 10.1016/j.canep.2019.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/17/2022]
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10
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Allan JN, Furman RR. Current trends in the management of Richter's syndrome. Int J Hematol Oncol 2019; 7:IJH09. [PMID: 30651968 PMCID: PMC6331753 DOI: 10.2217/ijh-2018-0010] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 11/21/2018] [Indexed: 12/16/2022] Open
Abstract
Richter's syndrome (RS) is a life-threatening complication of chronic lymphocytic leukemia (CLL). While previous research has increased our knowledge on the distinct evolutionary patterns of RS and provided a deeper understanding of the risk factors and molecular events predisposing to transformation, there remain few targetable aberrations and treatment is largely ineffective. The ability to obtain deeper remissions, without selecting for deletion 17p, by using novel B-cell receptor (BCR) antagonists and bcl2 inhibition might lead to a decrease in the incidence of RS, but these agents have done little to significantly change outcomes when incorporated into treatment regimens for RS. In this review we highlight the current landscape of molecular lesions specific to RS, review the data on historical treatment options, and look to the horizon for potential opportunities in the future.
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Affiliation(s)
- John N Allan
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
| | - Richard R Furman
- Department of Medicine, Division of Hematology & Medical Oncology, New York-Presbyterian Hospital, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065, USA
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Chen XL, Wang SF, Xu ZS. [The relationship between NOTCH1 mutation and the Richter transformation in chronic lymphocytic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:787-789. [PMID: 30369195 PMCID: PMC7342246 DOI: 10.3760/cma.j.issn.0253-2727.2018.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Indexed: 11/25/2022]
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12
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[The guidelines for diagnosis and treatment of chronic lymphocytic leukemia/small lymphocytic lymphoma in China (2018 edition)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:353-358. [PMID: 29779340 PMCID: PMC7342895 DOI: 10.3760/cma.j.issn.0253-2727.2018.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 12/21/2022]
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Rogers KA, Huang Y, Ruppert AS, Salem G, Stephens DM, Heerema NA, Andritsos LA, Awan FT, Byrd JC, Flynn JM, Maddocks KJ, Jones JA. A single-institution retrospective cohort study of first-line R-EPOCH chemoimmunotherapy for Richter syndrome demonstrating complex chronic lymphocytic leukaemia karyotype as an adverse prognostic factor. Br J Haematol 2017; 180:259-266. [PMID: 29193006 DOI: 10.1111/bjh.15035] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/26/2017] [Indexed: 01/23/2023]
Abstract
Richter Syndrome, an aggressive lymphoma occurring in patients with chronic lymphocytic leukaemia (CLL), has a generally poor prognosis and anthracycline-based chemoimmunotherapy regimens designed to treat de novo diffuse large B-cell lymphoma achieve modest clinical benefit. R-EPOCH (rituximab, etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) has demonstrated greater activity against aggressive B-cell histologies but has not been studied in Richter Syndrome. We conducted a retrospective cohort study of 46 Richter Syndrome patients treated with first-line R-EPOCH at our institution between 1 January 2006 and 31 May 2014. The median progression-free survival (PFS) was 3·5 months [95% confidence interval (CI): 2·0-7·6] and median overall survival (OS) was 5·9 months (95% CI: 3·2-10·3). Toxicity was high and 30% of patients died without progression or response. Patients with a complex CLL karyotype had significantly shorter PFS and OS (P = 0·005 and P = 0·002, respectively). Multivariable analysis identified complex CLL karyotype as the most significant predictor of decreased survival [Hazard ratio (HR) 2·72, 95% CI: 1·14-6·52, P = 0·025], adjusting for number of prior CLL treatments (P = 0·036). Richter Syndrome patients with complex CLL karyotype experience poor survival with R-EPOCH treatment and novel approaches are needed for these patients. In contrast, survival of patients without a complex CLL karyotype was similar to patients with de novo diffuse large B-cell lymphoma.
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Affiliation(s)
- Kerry A Rogers
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Ying Huang
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Amy S Ruppert
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Galena Salem
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | | | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH, USA
| | | | - Farrukh T Awan
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - John C Byrd
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Joseph M Flynn
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Kami J Maddocks
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Jeffrey A Jones
- Division of Hematology, The Ohio State University, Columbus, OH, USA
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14
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Salem A, Loghavi S, Khoury JD, Agbay RLMC, Jorgensen JL, Medeiros LJ. Herpes simplex infection simulating Richter transformation: a series of four cases and review of the literature. Histopathology 2016; 70:821-831. [PMID: 27905140 DOI: 10.1111/his.13137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/26/2016] [Indexed: 12/27/2022]
Abstract
AIMS Richter transformation (RT) occurs in 5-10% of patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL), and is associated with a poor outcome. The histological manifestations of RT are variable, and include an increase in the proportion of prolymphocytes, immunoblasts, and other pleomorphic cells, along with an increased proliferation rate and often necrosis. Rarely, superimposed herpes simplex virus (HSV) infection involving lymph nodes in patients with CLL/SLL may mimic RT clinically and histologically. In this study, we describe four cases of CLL/SLL with superimposed HSV lymphadenitis, and we review the literature. METHODS AND RESULTS We describe the clinicopathological and immunophenotypic findings of four cases of CLL/SLL with superimposed HSV infection. The patients presented with B-type symptoms, and laboratory and imaging findings suggested progression of lymphoma. Histologically, there were geographical areas of necrosis and increased numbers of prolymphocytes and immunoblasts, in some areas forming sheets, with increased mitotic figures and a high proliferation (Ki67) rate. However, the necrotic regions were associated with acute inflammatory cells and larger cells, mostly necrotic, showing viral cytopathic effects. Therapy with antiviral agents resulted in improvement of clinical symptoms and laboratory and imaging findings. Additionally, we identified 11 cases of CLL/SLL with superimposed HSV infection described in the English-language literature, and integrated the cases that we report here into this wider context. CONCLUSIONS Herpes simplex virus infection of lymph nodes in patients with CLL/SLL results in clinicopathological and radiological findings that may mimic RT. It is essential to refrain from misclassifying these cases as RT, as patients can respond remarkably well to antiviral therapy.
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Affiliation(s)
- Alireza Salem
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Rose Lou Marie C Agbay
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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15
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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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16
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Thyagarajan B, Alagusundaramoorthy SS, Shah L, Agrawal A. Richter's transformation presenting as splenic rupture after 6 years of complete remission of chronic lymphocytic leukaemia. BMJ Case Rep 2016; 2016:bcr-2016-214361. [PMID: 27288204 DOI: 10.1136/bcr-2016-214361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Richter's transformation is a rare clinical condition occurring in about 5-10% of patients with chronic lymphocytic leukaemia (CLL). Patients usually present with lymphadenopathy, hepatosplenomegaly and elevated serum lactate dehydrogenase levels. These patients have a very poor prognosis with a median survival of about 10 months. We present a patient, with a history of CLL in complete remission, who presented with splenic rupture requiring splenectomy. She was eventually diagnosed with diffuse large B-cell lymphoma with Richter's transformation.
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Affiliation(s)
| | | | - Lopa Shah
- Department of Pathology, Monmouth Medical Center, Long Branch, New Jersey, USA
| | - Abhinav Agrawal
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
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17
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High-grade Transformation of Low-grade B-cell Lymphoma: Pathology and Molecular Pathogenesis. Am J Surg Pathol 2016; 40:e1-16. [PMID: 26658667 DOI: 10.1097/pas.0000000000000561] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Patients with low-grade (clinically indolent) lymphomas are at risk to undergo transformation to high-grade (clinically aggressive) lymphoma, although transformation only occurs in a subset of patients. When transformation occurs it is a critical event that determines the course of disease and is associated with unfavorable patient outcomes. Accurate detection of transformation, predictive biomarkers, and identification of specific molecular pathways implicated in the pathobiology of transformation will facilitate personalized therapeutic approaches and underpin advances in clinical outcomes. In this article, we present an update of the clinical and pathologic diagnostic criteria for low-grade B-cell lymphoma transformation and discuss the molecular alterations involved in the pathogenesis of this biological phenomenon.
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18
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Woroniecka R, Rymkiewicz G, Grygalewicz B, Błachnio K, Rygier J, Jarmuż-Szymczak M, Ratajczak B, Pieńkowska-Grela B. Cytogenetic and flow cytometry evaluation of Richter syndrome reveals MYC, CDKN2A, IGH alterations with loss of CD52, CD62L and increase of CD71 antigen expression as the most frequent recurrent abnormalities. Am J Clin Pathol 2015; 143:25-35. [PMID: 25511139 DOI: 10.1309/ajcpatrqwanw2o3n] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Richter syndrome (RS) is a transformation of chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) into high-grade lymphoma. There are only limited data on flow cytometry (FCM) and cytogenetics in RS. METHODS In this study, FCM, classic cytogenetics (CC), and fluorescence in situ hybridization (FISH) were performed in eight RS cases. RESULTS Most cases of RS were characterized by a loss/decrease of CD52 and CD62L and increased CD71 expression. CC identified complex karyotypes, with losses of 9/9p and 17/17p as the most frequent in four of seven cases. Seven RS cases demonstrated MYC abnormalities. Disruptions of CDKN2A and IGH were identified in five of seven and four of seven RS cases, respectively. CONCLUSIONS Newly diagnosed RS is an oncologic emergency, and a quick diagnostic decision is crucial in clinical practice. Therefore, in patients with CLL/SLL and rapidly enlarging asymmetric lymphadenopathy and/or extranodal tumors, we strongly advise FCM of fine-needle aspiration biopsy (FNAB) material, including CD62L, CD52, and CD71 analysis as well as assessment of karyotype and at least MYC abnormalities by FISH of the same FNAB material. Loss of CD52 expression in RS most likely predicts resistance to alemtuzumab therapy, which is frequently used in CLL.
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Affiliation(s)
- Renata Woroniecka
- Cancer Genetics Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
| | - Grzegorz Rymkiewicz
- Flow Cytometry Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
| | - Beata Grygalewicz
- Cancer Genetics Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
| | - Katarzyna Błachnio
- Flow Cytometry Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
| | - Jolanta Rygier
- Cancer Genetics Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
| | - Małgorzata Jarmuż-Szymczak
- Department of Hematology and Bone Marrow Transplantation, University of Medical Sciences, Poznań, Poland
- Institute of Human Genetics, Polish Academy of Sciences, Poznań, Poland
| | - Błażej Ratajczak
- Department of Hematology and Bone Marrow Transplantation, University of Medical Sciences, Poznań, Poland
| | - Barbara Pieńkowska-Grela
- Cancer Genetics Laboratory of the Pathology Department and Laboratory Diagnostics, the Maria Skłodowska-Curie Memorial Institute and Cancer Centre, Warszawa, Poland
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20
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Gogia A, Raina V, Kumar L, Sharma A, Mehta P, Sharma MC. Diffuse large B-cell lymphoma in patients with chronic lymphocytic leukemia: A single center experience. South Asian J Cancer 2014; 3:186. [PMID: 25136531 PMCID: PMC4134615 DOI: 10.4103/2278-330x.136814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ajay Gogia
- Department of Medical Oncology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
| | - Vinod Raina
- Department of Medical Oncology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
| | - Prashant Mehta
- Department of Medical Oncology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
| | - Mehar Chander Sharma
- Department of Pathology, Dr. Bhimrao Ramji Ambedkar Institute Rotary Cancer Hospital, All IndiaInstitute of Medical Sciences, New Delhi, India
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21
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Frankfurt O, Ma S, Gordon L, Winter JN, Horowitz JM, Rademaker A, Weitner BB, Peterson LC, Altman JK, Tallman MS, Petrich A, Rosen ST. Phase II study of alemtuzumab-rituximab therapy in previously untreated patients with chronic lymphocytic leukemia: short- and long-term outcomes. Leuk Lymphoma 2014; 56:315-23. [PMID: 24707943 DOI: 10.3109/10428194.2014.910654] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We investigated the safety, efficacy, and long-term outcomes of alemtuzumab and rituximab (AR) combination therapy in previously untreated patients with CLL. Thirty patients, ages 28-80 years, 47% older than 60 years, 90% Rai clinical stages II-IV, and 67% without favorable cytogenetics received AR. Based on the NCI-WG 1996 criteria, OR was 100%, with 60% CR. With CT scans OR was 70%, with 23% CR, 47% PR, and 30% SD. Sixty-seven percent of patients showed no evidence of MRD in the bone marrow by 6-color flow cytometry. Median PFS, TFS, and 5-year OS were 24.4, 50.7 months, and 80%, respectively. Grade 3/4 neutropenia and thrombocytopenia were reported in 30% and 7% of patients, respectively. CMV reactivation, asymptomatic in all but one patient, occurred in 8 patients. Immunotherapy with alemtuzumab and rituximab results in robust responses and long asymptomatic therapy-free intervals. It is well tolerated with infrequent, predictable, and easily managed complications.
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Affiliation(s)
- Olga Frankfurt
- Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center , Chicago, IL , USA
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22
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Parikh SA, Kay NE, Shanafelt TD. How we treat Richter syndrome. Blood 2014; 123:1647-57. [PMID: 24421328 PMCID: PMC3954047 DOI: 10.1182/blood-2013-11-516229] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/07/2014] [Indexed: 01/13/2023] Open
Abstract
Richter syndrome (RS) is defined as the transformation of chronic lymphocytic leukemia (CLL) into an aggressive lymphoma, most commonly diffuse large B-cell lymphoma (DLBCL). RS occurs in approximately 2% to 10% of CLL patients during the course of their disease, with a transformation rate of 0.5% to 1% per year. A combination of germline genetic characteristics, clinical features (eg, advanced Rai stage), biologic (ζ-associated protein-70(+), CD38(+), CD49d(+)) and somatic genetic (del17p13.1 or del11q23.1) characteristics of CLL B cells, and certain CLL therapies are associated with higher risk of RS. Recent studies have also identified the crucial role of CDKN2A loss, TP53 disruption, C-MYC activation, and NOTCH1 mutations in the transformation from CLL to RS. An excisional lymph node biopsy is considered the gold standard for diagnosis of RS; a (18)F-fluorodeoxyglucose positron emission tomography scan can help inform the optimal site for biopsy. Approximately 80% of DLBCL cases in patients with CLL are clonally related to the underlying CLL, and the median survival for these patients is approximately 1 year. In contrast, the remaining 20% of patients have a clonally unrelated DLBCL and have a prognosis similar to that of de novo DLBCL. For patients with clonally related DLBCL, induction therapy with either an anthracycline- or platinum-based regimen is the standard approach. Postremission stem cell transplantation should be considered for appropriate patients. This article summarizes our approach to the clinical management of CLL patients who develop RS.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/pathology
- Combined Modality Therapy
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Middle Aged
- Prognosis
- Stem Cell Transplantation
- Transplantation, Autologous
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Affiliation(s)
- Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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Fiegl M, Stauder R, Steurer M, Mian M, Hopfinger G, Brychtova Y, Skrabs C, Zabernigg A, Schmid F, Haslbaur F, Winder G, Walder A, Lang A, Voskova D, Greil R, Mayer J, Gastl G. Alemtuzumab in chronic lymphocytic leukemia: final results of a large observational multicenter study in mostly pretreated patients. Ann Hematol 2013; 93:267-77. [PMID: 24292560 DOI: 10.1007/s00277-013-1966-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 11/13/2013] [Indexed: 12/11/2022]
Abstract
This retrospective study evaluated the benefit of alemtuzumab monotherapy in unselected patients with advanced B-cell chronic lymphocytic leukemia (CLL) and prolymphocytic leukemia (B-PLL) to definitely describe the impact of this antibody in clinical routine use. Data were collected from 208 consecutive, mainly pretreated, patients with CLL (n = 202), and B-PLL (n = 6) who had received alemtuzumab. Response, progression-free survival (PFS), and overall survival (OS) in various settings were assessed, and toxicities were documented. In these routine patients, a comparably low cumulative dose of alemtuzumab (median, 403 mg) was applied. In CLL, overall response rate was 32 %, and various pre-therapeutic parameters were predictive for inferior response, among them, the prior administration of ≥3 therapy lines (P < 0.001), refractoriness to fludarabine (P = 0.002), and bulky lymphadenopathy (P = 0.003). PFS and OS after start of alemtuzumab were 6.2 and 21.0 months, respectively. Bulky lymphadenopathy was the prominent risk factor for both inferior PFS (P < 0.001) and OS (P = 0.002). In B-PLL, four patients experienced a fatal outcome, whereas two patients had some benefit with alemtuzumab. The main adverse effects were CMV reactivation (20 %) and a broad spectrum of infections, which together were the main reasons for treatment interruption and/or premature termination. In conclusion, alemtuzumab administered even at low dose levels was effective but overall considerably toxic in routine CLL patients. We emphasize that alemtuzumab remains an important therapeutic option in subsets of CLL patients.
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Affiliation(s)
- M Fiegl
- Department of Internal Medicine V (Hematology and Oncology), Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria,
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24
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Parikh SA, Rabe KG, Call TG, Zent CS, Habermann TM, Ding W, Leis JF, Schwager SM, Hanson CA, Macon WR, Kay NE, Slager SL, Shanafelt TD. Diffuse large B-cell lymphoma (Richter syndrome) in patients with chronic lymphocytic leukaemia (CLL): a cohort study of newly diagnosed patients. Br J Haematol 2013; 162:774-82. [PMID: 23841899 DOI: 10.1111/bjh.12458] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/09/2013] [Indexed: 11/29/2022]
Abstract
Nearly all information about patients with chronic lymphocytic leukaemia (CLL) who develop diffuse large B-cell lymphoma [Richter syndrome (RS)] is derived from retrospective case series or patients treated on clinical trials. We used the Mayo Clinic CLL Database to identify patients with newly diagnosed CLL between January 2000 and July 2011. Individuals who developed biopsy-proven RS during follow-up were identified. After a median follow-up of 4 years, 37/1641 (2·3%) CLL patients developed RS. The rate of RS was approximately 0·5%/year. Risk of RS was associated with advanced Rai stage at diagnosis (P < 0·001), high-risk genetic abnormalitites on fluorescence in situ hybridization (P < 0·0001), unmutated IGHV (P = 0·003), and expression of ZAP70 (P = 0·02) and CD38 (P = 0·001). The rate of RS doubled in patients after treatment for CLL (1%/year). Stereotyped B-cell receptors (odds-ratio = 4·2; P = 0·01) but not IGHV4-39 family usage was associated with increased risk of RS. Treatment with combination of purine analogues and alkylating agents increased the risk of RS three-fold (odds-ratio = 3·26, P = 0·0003). Median survival after RS diagnosis was 2·1 years. The RS prognosis score stratified patients into three risk groups with median survivals of 0·5 years, 2·1 years and not reached. Both underlying characteristics of the CLL clone and subsequent CLL therapy influence the risk of RS. Survival after RS remains poor and new therapies are needed.
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Affiliation(s)
- Sameer A Parikh
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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