1
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Kapoor P, Rajkumar SV. Current approach to Waldenström macroglobulinemia. Blood Rev 2023; 62:101129. [PMID: 37659912 PMCID: PMC10841191 DOI: 10.1016/j.blre.2023.101129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023]
Abstract
Waldenström macroglobulinemia (WM) is a unique CD20+, B-cell non-Hodgkin lymphoma, characterized by lymphoplasmacytic infiltration of the bone marrow and circulating monoclonal immunoglobulin M. The clinical manifestations and outcomes of patients are highly variable. High-level evidence supports integration of monoclonal anti-CD20 antibody, rituximab, to the chemotherapy backbone to treat WM. However, its contemporary management has become more nuanced, with deeper understanding of the pathophysiology and incorporation of Bruton's tyrosine kinase (BTK) inhibitors to the treatment paradigm. Prior knowledge of the patients' MYD88L265P and CXCR4 mutation status may aid in the treatment decision-making. Currently, the two frequently utilized approaches include fixed-duration chemoimmunotherapy and BTK inhibitor-based continuous treatment until progression. Randomized trials comparing these two vastly divergent approaches are lacking. Recent studies demonstrating efficacy of B cell lymphoma-2 (BCL2) inhibitors and non-covalent BTK inhibitors in patients, previously exposed to a covalent BTK inhibitor, are a testament to the rapidly expanding options against WM.
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2
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Chan WL, Chong VCL, Wee IJY, Poon LM, Chan EHL, Lee J, Chee YL, Jeyasekharan AD, Chng WJ, Samuel M, de Mel S. Efficacy and safety of front-line treatment regimens for Waldenstrom macroglobulinaemia: a systematic review and meta-analysis. Blood Cancer J 2023; 13:140. [PMID: 37679351 PMCID: PMC10485051 DOI: 10.1038/s41408-023-00916-5] [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: 06/29/2023] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023] Open
Abstract
Rituximab-based chemo-immunotherapy is currently the standard first-line treatment for Waldenstrom macroglobulinaemia (WM), while ibrutinib has emerged as an alternative. In the absence of randomised trials (RCTs) comparing these regimens, the optimal first-line treatment for WM remains uncertain. In this systematic review and meta-analysis, we sought to assess the efficacy and safety of first-line treatment regimens for WM. We searched key databases from January 2007 to March 2023, including phase II and III trials, including treatment-naïve WM patients treated with rituximab-based regimens or ibrutinib. Response rates, progression-free survival (PFS), overall survival (OS), and toxicities were evaluated. Four phase III and seven phase II trials were included among 736 unique records. Pooled response rates from all comparative and non-comparative trials were 46%, 33% and 26% for bendamustine rituximab (BR), bortezomib-dexamethasone, cyclophosphamide, rituximab (BDRC) and ibrutinib rituximab (IR), respectively. Two-year pooled PFS was 89%, 81% and 82% with BR, BDRC and IR, respectively. Neuropathy was more frequent with bortezomib, while haematologic and cardiac toxicities were more common with chemo-immunotherapy and ibrutinib-based regimens respectively. Our findings suggest that BR yields higher response rates than bortezomib or ibrutinib-based combinations. RCTs comparing BR against emerging therapies, including novel Bruton Tyrosine Kinase Inhibitors, are warranted.
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Affiliation(s)
- Wee-Lee Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | | | - Ian Jun Yan Wee
- Department of Surgery, Singapore General Hospital, Singapore, Singapore
| | - Li Mei Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Esther Hian Lee Chan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Joanne Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Yen-Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Wee-Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Miny Samuel
- Research Support Unit, National University of Singapore, Singapore, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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3
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Waldenström Macroglobulinemia: Mechanisms of Disease Progression and Current Therapies. Int J Mol Sci 2022; 23:ijms231911145. [PMID: 36232447 PMCID: PMC9569492 DOI: 10.3390/ijms231911145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Waldenström macroglobulinemia is an indolent, B-cell lymphoma without a known cure. The bone marrow microenvironment and cytokines both play key roles in Waldenström macroglobulinemia (WM) tumor progression. Only one FDA-approved drug exists for the treatment of WM, Ibrutinib, but treatment plans involve a variety of drugs and inhibitors. This review explores avenues of tumor progression and targeted drug therapy that have been investigated in WM and related B-cell lymphomas.
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4
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Ravi G, Kapoor P. Current approach to Waldenström Macroglobulinemia. Cancer Treat Res Commun 2022; 31:100527. [PMID: 35149375 DOI: 10.1016/j.ctarc.2022.100527] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 01/20/2022] [Accepted: 01/30/2022] [Indexed: 06/14/2023]
Abstract
Waldenström Macroglobulinemia (WM) is a unique, low grade, IgM lymphoplasmacytic lymphoma with a heterogeneous clinical course. A paucity of high-grade evidence from large phase 3 trials remains a major issue in the field despite a rapidly expanding therapeutic armamentarium against WM. Prior knowledge of the patients' MYD88L265P and CXCR4 mutation status aids in treatment decision making if Bruton's tyrosine kinase (BTK) inhibitor therapy is being considered. Head-to head comparative data to inform optimal approach are lacking, and a particularly vexing issue for the clinicians is choosing between fixed-duration bendamustine-rituximab (BR) therapy and an indefinite BTK inhibitor-based regimen, given that both approaches are well tolerated and effective, particularly for the patient population harboring MYD88L265P mutation. For the patients with MYD88WT genotype, chemo-immunotherapy such as BR is preferred, although zanubrutinib, a potent second generation BTK inhibitor, with its reduced off target effects and greater BTK occupancy compared to its predecessor, ibrutinib, has also recently shown activity in MYD88WT WM. This review summarizes the current literature pertaining to the diagnosis, prognosis, and the treatment of WM.
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Affiliation(s)
- Gayathri Ravi
- Division of Hematology Mayo Clinic, Rochester, MN, United States of America
| | - Prashant Kapoor
- Division of Hematology Mayo Clinic, Rochester, MN, United States of America.
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5
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Ahmed S, Zhao Q, Hanel W, Qazilbash MH, Patel K, Narra R, Kansagra A, Iqbal M, Awan FT, Christian B, Jaglowski SM, Kharfan-Dabaja MA, Hamadani M, Epperla N. Post-relapse survival in Waldenstrom macroglobulinemia patients experiencing therapy failure following autologous transplantation. Hematol Oncol 2021; 40:48-56. [PMID: 34763367 DOI: 10.1002/hon.2946] [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: 07/15/2021] [Revised: 10/18/2021] [Accepted: 11/09/2021] [Indexed: 11/05/2022]
Abstract
Waldenström macroglobulinemia (WM) is a rare B-cell lymphoproliferative malignancy. Autologous hematopoietic cell transplantation (auto-HCT) is considered in a subset of WM patients with relapsed disease. While registry data has shown a benefit for auto-HCT in relapsed WM, there is a paucity of data on outcomes of patients relapsing after auto-HCT. Eligibility criteria included adult patients with relapsed/refractory WM who underwent auto-HCT between 2007 and 2017. The primary endpoint was post-relapse overall survival (PR-OS). Secondary endpoints were to identify factors prognostic of PR-OS. Of the 48 patients with WM who underwent auto-HCT, 22 (46%) experienced relapse following auto-HCT. Median PR-OS of relapsed WM patients after auto-HCT (n = 22) was not reached (NR) (95% confidence interval [CI]: 17.5 months-NR). Among patients who relapsed <1 year versus ≥1 year from auto-HCT, the median PR-OS was 18.4 months (95%CI: 0.8-NR) months and NR (95%CI: 17.5-NR), respectively (p = 0.06). Of note, disease status at the time of transplant, CR/VGPR versus partial remission did not appear to impact PR-OS. The median PR-OS was significantly longer in patients who received ibrutinib in the post-transplant setting compared to those who did not (NR vs. 18.4 months, 95%CI: 9.1-NR, p = 0.02). On univariable analysis, the presence of complex karyotype (RR = 4.87, 95% CI = 1.22-19.53) and a higher number of prior lines of therapy (RR = 1.81, 95% CI = 1.23-2.67) were associated with a significantly higher risk of relapse. This is the only study to date that evaluated outcomes of WM patients who relapsed following auto-HCT and provides a benchmark for future trials evaluating survival following auto-HCT relapse.
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Affiliation(s)
- Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas, USA.,Department of Lymphoma and Myeloma, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Qiuhong Zhao
- Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Walter Hanel
- Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Krina Patel
- Department of Lymphoma and Myeloma, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Ravi Narra
- Department of Medicine, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ankit Kansagra
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Farrukh T Awan
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Beth Christian
- Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Samantha M Jaglowski
- Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Mehdi Hamadani
- Department of Medicine, BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Narendranath Epperla
- Division of Hematology, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, Ohio, USA
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6
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Gertz MA. Waldenström macroglobulinemia: 2021 update on diagnosis, risk stratification, and management. Am J Hematol 2021; 96:258-269. [PMID: 33368476 DOI: 10.1002/ajh.26082] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 02/06/2023]
Abstract
DISEASE OVERVIEW Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with immunoglobulin M (IgM) monoclonal protein. Clinical features include anemia, thrombocytopenia, hepatosplenomegaly, lymphadenopathy, and rarely hyperviscosity. DIAGNOSIS Presence of IgM monoclonal protein associated with ≥10% clonal lymphoplasmacytic cells in bone marrow confirms the diagnosis. The L265P mutation in MYD88 is detectable in more than 90% of patients and is found in the majority of IgM MGUS patients. RISK STRATIFICATION Age, hemoglobin level, platelet count, β2 microglobulin, LDH and monoclonal IgM concentrations are characteristics that are predictive of outcomes. RISK-ADAPTED THERAPY Not all patients who fulfill WM criteria require therapy; these patients can be observed until symptoms develop. Rituximab-monotherapy is inferior to regimens that combine it with bendamustine, an alkylating agent, a proteosome inhibitor, or ibrutinib. Purine nucleoside analogues are active but usage is declining in favor of less toxic alternatives. The preferred Mayo Clinic induction is rituximab and bendamustine. MANAGEMENT OF REFRACTORY DISEASE Bortezomib, fludarabine, thalidomide, everolimus, Bruton Tyrosine Kinase inhibitors, carfilzomib, lenalidomide, and bendamustine have all been shown to have activity in relapsed WM. Given WM's natural history, reduction of therapy toxicity is an important part of treatment selection.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Visco C, Tanasi I, Quaglia FM, Ferrarini I, Fraenza C, Krampera M. Oncogenic Mutations of MYD88 and CD79B in Diffuse Large B-Cell Lymphoma and Implications for Clinical Practice. Cancers (Basel) 2020; 12:E2913. [PMID: 33050534 PMCID: PMC7600909 DOI: 10.3390/cancers12102913] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/01/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin's lymphoma in adults. Despite the recognition of transcriptional subtypes with distinct functional characteristics, patient outcomes have not been substantially altered since the advent of chemoimmunotherapy (CIT) twenty years ago. Recently, a few pivotal studies added to the disease heterogeneity by describing several activating mutations, which have been associated with disease presentation, B-cell function and behavior, and final outcome. DLBCL arises from antigen exposed B-cells, with the B-cell receptor (BCR) playing a central role. BCR-activity related mutations, such as CD79B and MYD88, are responsible for chronic activation of the BCR in a substantial subset of patients. These mutations, often coexisting in the same patient, have been found in a substantial subset of patients with immune-privileged (IP) sites DLBCLs, and are drivers of lymphoma development conferring tissue-specific homing properties. Both mutations have been associated with disease behavior, including tumor response either to CIT or to BCR-targeted therapy. The recognition of CD79B and MYD88 mutations will contribute to the heterogeneity of the disease, both in recognizing the BCR as a potential therapeutic target and in providing genetic tools for personalized treatment.
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Affiliation(s)
- Carlo Visco
- Correspondence: (C.V.); (I.T.); Tel.: +39-0458124797 (C.V.); +39-0458128418 (I.T.)
| | - Ilaria Tanasi
- Correspondence: (C.V.); (I.T.); Tel.: +39-0458124797 (C.V.); +39-0458128418 (I.T.)
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8
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Grimont CN, Castillo Almeida NE, Gertz MA. Current and Emerging Treatments for Waldenström Macroglobulinemia. Acta Haematol 2020; 144:146-157. [PMID: 32810857 DOI: 10.1159/000509286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 12/30/2022]
Abstract
Waldenström macroglobulinemia (WM) is a rare lymphoplasmacytic lymphoma. The primary goal of therapy is to reduce symptoms related to direct infiltration of the bone marrow and decrease monoclonal IgM-associated complications. Active agents in the management of WM can be broadly classified as rituximab-alkylator combination therapy, proteasome inhibitor-based therapy, and Bruton's tyrosine kinase inhibitor-based therapy. MYD88L265P and CXCR4 genetic status are pivotal for tailoring treatment options. Ibrutinib is a suitable treatment option for both treatment-naïve and relapsing WM patients. Recent advances in the intracellular B cell and cytokine signaling pathways have contributed to the development of novel therapeutic strategies. Current clinical trials are promising and may further advance WM-directed therapy.
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Affiliation(s)
- Christopher N Grimont
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Natalia E Castillo Almeida
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA,
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9
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Treon SP, Xu L, Guerrera ML, Jimenez C, Hunter ZR, Liu X, Demos M, Gustine J, Chan G, Munshi M, Tsakmaklis N, Chen JG, Kofides A, Sklavenitis-Pistofidis R, Bustoros M, Keezer A, Meid K, Patterson CJ, Sacco A, Roccaro A, Branagan AR, Yang G, Ghobrial IM, Castillo JJ. Genomic Landscape of Waldenström Macroglobulinemia and Its Impact on Treatment Strategies. J Clin Oncol 2020; 38:1198-1208. [PMID: 32083995 DOI: 10.1200/jco.19.02314] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Next-generation sequencing has revealed recurring somatic mutations in Waldenström macroglobulinemia (WM), including MYD88 (95%-97%), CXCR4 (30%-40%), ARID1A (17%), and CD79B (8%-15%). Deletions involving chromosome 6q are common in patients with mutated MYD88 and include genes that modulate NFKB, BCL2, Bruton tyrosine kinase (BTK), and apoptosis. Patients with wild-type MYD88 WM show an increased risk of transformation and death and exhibit many mutations found in diffuse large B-cell lymphoma. The discovery of MYD88 and CXCR4 mutations in WM has facilitated rational drug development, including the development of BTK and CXCR4 inhibitors. Responses to many agents commonly used to treat WM, including the BTK inhibitor ibrutinib, are affected by MYD88 and/or CXCR4 mutation status. The mutation status of both MYD88 and CXCR4 can be used for a precision-guided treatment approach to WM.
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Affiliation(s)
- Steven P Treon
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Lian Xu
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Maria Luisa Guerrera
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Cristina Jimenez
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Zachary R Hunter
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Xia Liu
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Maria Demos
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Joshua Gustine
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Gloria Chan
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Manit Munshi
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Nicholas Tsakmaklis
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Jiaji G Chen
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Amanda Kofides
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Romanos Sklavenitis-Pistofidis
- Department of Medicine, Harvard Medical School, Boston, MA.,Center for Prevention of Progression of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA.,Clinical Research Development and Phase I Unit, CREA Laboratory, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, Brescia, Italy
| | - Mark Bustoros
- Department of Medicine, Harvard Medical School, Boston, MA.,Center for Prevention of Progression of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Keezer
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | - Kirsten Meid
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA
| | | | - Antonio Sacco
- Center for Prevention of Progression of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA.,Clinical Research Development and Phase I Unit, CREA Laboratory, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, Brescia, Italy
| | - Aldo Roccaro
- Clinical Research Development and Phase I Unit, CREA Laboratory, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, Brescia, Italy
| | - Andrew R Branagan
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA
| | - Guang Yang
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
| | - Irene M Ghobrial
- Department of Medicine, Harvard Medical School, Boston, MA.,Center for Prevention of Progression of Blood Cancers, Dana-Farber Cancer Institute, Boston, MA
| | - Jorge J Castillo
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA.,Department of Medicine, Harvard Medical School, Boston, MA
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10
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Imaging of Waldenström Macroglobulinemia: A Comprehensive Review for the Radiologist in the Era of Personalized Medicine. AJR Am J Roentgenol 2019; 213:W248-W256. [PMID: 31287727 DOI: 10.2214/ajr.19.21493] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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de Groen RAL, Schrader AMR, Kersten MJ, Pals ST, Vermaat JSP. MYD88 in the driver's seat of B-cell lymphomagenesis: from molecular mechanisms to clinical implications. Haematologica 2019; 104:2337-2348. [PMID: 31699794 PMCID: PMC6959184 DOI: 10.3324/haematol.2019.227272] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022] Open
Abstract
More than 50 subtypes of B-cell non-Hodgkin lymphoma (B-NHL) are recognized in the most recent World Health Organization classification of 2016. The current treatment paradigm, however, is largely based on 'one-size-fits-all' immune-chemotherapy. Unfortunately, this therapeutic strategy is inadequate for a significant number of patients. As such, there is an indisputable need for novel, preferably targeted, therapies based on a biologically driven classification and risk stratification. Sequencing studies identified mutations in the MYD88 gene as an important oncogenic driver in B-cell lymphomas. MYD88 mutations constitutively activate NF-κB and its associated signaling pathways, thereby promoting B-cell proliferation and survival. High frequencies of the hotspot MYD88(L265P) mutation are observed in extranodal diffuse large B-cell lymphoma and Waldenström macroglobulinemia, thereby demonstrating this mutation's potential as a disease marker. In addition, the presence of mutant MYD88 predicts survival outcome in B-NHL subtypes and it provides a therapeutic target. Early clinical trials targeting MYD88 have shown encouraging results in relapsed/refractory B-NHL. Patients with these disorders can benefit from analysis for the MYD88 hotspot mutation in liquid biopsies, as a minimally invasive method to demonstrate treatment response or resistance. Given these clear clinical implications and the crucial role of MYD88 in lymphomagenesis, we expect that analysis of this gene will increasingly be used in routine clinical practice, not only as a diagnostic classifier, but also as a prognostic and therapeutic biomarker directing precision medicine. This review focuses on the pivotal mechanistic role of mutated MYD88 and its clinical implications in B-NHL.
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Affiliation(s)
| | | | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam.,Lymphoma and Myeloma Center Amsterdam-LYMMCARE, Amsterdam.,Cancer Center Amsterdam, Amsterdam
| | - Steven T Pals
- Department of Hematology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam.,Cancer Center Amsterdam, Amsterdam.,Department of Pathology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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12
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Gertz MA. Waldenström macroglobulinemia: 2019 update on diagnosis, risk stratification, and management. Am J Hematol 2019; 94:266-276. [PMID: 30328142 DOI: 10.1002/ajh.25292] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 12/30/2022]
Abstract
DISEASE OVERVIEW Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with immunoglobulin M (IgM) monoclonal protein. Clinical features include anemia, thrombocytopenia, hepatosplenomegaly, lymphadenopathy, and rarely hyperviscosity. DIAGNOSIS Presence of IgM monoclonal protein associated with ≥10% clonal lymphoplasmacytic cells in bone marrow confirms the diagnosis. The L265P mutation in MYD88 is detectable in >90% of patients and is found in the majority of IgM monoclonal gammopathy of undetermined significance patients. RISK STRATIFICATION Age, hemoglobin level, platelet count, β2 microglobulin, and monoclonal IgM concentrations are characteristics that are predictive of outcomes. RISK-ADAPTED THERAPY Not all patients who fulfill WM criteria require therapy; these patients can be observed until symptoms develop. Rituximab-monotherapy is inferior to regimens that combine it with bendamustine, an alkylating agent, a proteosome inhibitor, or ibrutinib. Purine nucleoside analogs are active but usage is declining for less toxic alternatives. The preferred Mayo Clinic induction is rituximab and bendamustine. Potential for stem cell transplantation should be considered in selected younger patients. MANAGEMENT OF REFRACTORY DISEASE Bortezomib, fludarabine, thalidomide, everolimus, ibrutinib, carfilzomib, lenalidomide, and bendamustine have all been shown to have activity in relapsed WM. Given WM's natural history, reduction of therapy toxicity is an important part of treatment selection.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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13
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Spinner MA, Varma G, Advani RH. Novel Approaches in Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2018; 32:875-890. [DOI: 10.1016/j.hoc.2018.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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Tedeschi A, Conticello C, Rizzi R, Benevolo G, Laurenti L, Petrucci MT, Zaja F, Varettoni M. Diagnostic framing of IgM monoclonal gammopathy: Focus on Waldenström macroglobulinemia. Hematol Oncol 2018; 37:117-128. [DOI: 10.1002/hon.2539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/12/2018] [Accepted: 07/12/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Alessandra Tedeschi
- Department of HematologyNiguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda Milan Italy
| | - Concetta Conticello
- Department of Clinical and Molecular Biomedicine, Haematology SectionUniversity of Catania Catania Italy
| | - Rita Rizzi
- Department of Emergency and Organ Transplantation, Hematology SectionUniversity of Bari Medical School Bari Italy
| | - Giulia Benevolo
- Division of HematologyAOU Città della Salute e della Scienza Torino Italy
| | - Luca Laurenti
- Department of HematologyCatholic University Hospital “A. Gemelli” Rome Italy
| | - Maria Teresa Petrucci
- Hematology, Department of Cellular Biotechnologies and Hematology“Sapienza” University Rome Italy
| | - Francesco Zaja
- Clinica Ematologica, Centro Trapianti e Terapie Cellulari “Carlo Melzi”University of Udine Udine Italy
| | - Marzia Varettoni
- Division of HematologyFondazione IRCCS Policlinico S. Matteo Pavia Italy
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15
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European myeloma network recommendations on diagnosis and management of patients with rare plasma cell dyscrasias. Leukemia 2018; 32:1883-1898. [DOI: 10.1038/s41375-018-0209-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/28/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
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16
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A Novel Combination of the mTORC1 Inhibitor Everolimus and the Immunomodulatory Drug Lenalidomide Produces Durable Responses in Patients With Heavily Pretreated Relapsed Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:664-672.e2. [PMID: 30104176 DOI: 10.1016/j.clml.2018.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/03/2018] [Accepted: 06/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment outcomes have improved in lymphoid malignancies but relapse remains inevitable for most patients. Everolimus and lenalidomide have shown clinical activity as single agents in patients with relapsed and refractory Hodgkin and non-Hodgkin lymphomas. PATIENTS AND METHODS The present phase I/II trial for patients with relapsed and refractory lymphoid malignancy opened at Mayo Clinic from January 2011 to May 2013. The trial used a standard cohort 3 + 3 design to determine the maximum tolerated dose for the combination. Stem cell transplantation had failed in 27 of the patients (49%), 63% had stage IV disease, and ≥ 3 previous therapies had failed in 78%. RESULTS Of the 58 patients, enrolled, 55 were evaluable for analysis. The maximum tolerated dose was 5 mg/d for everolimus plus 10 mg/d for 21 days for lenalidomide. The most common grade ≥ 3 toxicities were hematologic and included neutropenia (56%), leukopenia (38%), and thrombocytopenia (33%). Seven patients discontinued the study because of adverse events. One patient died of disease progression. The overall response rate was 27% (15 of 55), with 38% (21 of 55) having stable disease. CONCLUSION The present phase I/II trial of everolimus and lenalidomide for R/R lymphoma has shown the combination to be tolerable, with neutropenia as the main dose-limiting toxicity. Encouraging responses were seen in this heavily pretreated group, and the patients with a response had meaningful duration of response.
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García-Sanz R, Jiménez C, González De La Calle V, Sarasquete ME. A safety profile of medications used to treat Waldenström's macroglobulinemia. Expert Opin Drug Saf 2018; 17:609-621. [PMID: 29768934 DOI: 10.1080/14740338.2018.1477936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Waldenström's macroglobulinemia (WM) is a B-cell lymphoproliferative disease with serum IgM monoclonal component and bone marrow infiltration by lymphoplasmacytic lymphoma. Traditional therapy was based on that regimens used for closely related entities, such as chronic lymphocytic leukemia or multiple myeloma. This resulted in a lack of drugs specifically approved for WM, until the discovery of the Bruton Tyrosine Kinase (BTK) inhibitors. AREAS COVERED Two main therapeutic attitudes are possible: (1) conventional therapies based on combinations with alkylating agents or proteasome inhibitors with steroids and anti-CD20 monoclonal antibodies or (2) new approaches with BTK inhibitors, usually alone. Other possibilities such as BCL2 inhibitors, PI3K/AKT inhibitors, and others are currently under evaluation, but we will focus the review on the most consolidated approaches that are available for patients with WM at different stages of the disease. PubMed, Web of Science, and clinicaltrials.gov were queried for the keywords 'Waldenstrom macroglobulinemia' and the different drugs here evaluated through 1 February 2018. EXPERT OPINION Although WM has no many specific drugs, there are many possible therapies, including Ibrutinib, the first formally approved drug for this disorder.
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Affiliation(s)
- Ramón García-Sanz
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - Cristina Jiménez
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - Verónica González De La Calle
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
| | - María Eugenia Sarasquete
- a Servicio de Hematología, Hospital Universitario de Salamanca , Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, CIBERONC , Salamanca , Spain
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18
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Gertz MA. Waldenström macroglobulinemia treatment algorithm 2018. Blood Cancer J 2018; 8:40. [PMID: 29712895 PMCID: PMC5928091 DOI: 10.1038/s41408-018-0076-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 12/11/2022] Open
Abstract
Waldenström macroglobulinemia is often an indolent disorder, and many patients are candidates for observation with careful monitoring. For symptomatic patients, one must distinguish between those patients whose symptoms are related to immunologic manifestations associated with the IgM monoclonal protein and those that have symptoms related to progressive marrow and nodal infiltration with lymphoplasmacytic lymphoma. In Waldenström macroglobulinemia, the driver for therapy in the majority of patients is progressive anemia, secondary to bone marrow replacement by lymphoplasmacytic lymphoma. Recent introduction of MYD88 mutational analysis has been very useful for diagnostic purposes but is unclear what effect it might have on the prognosis or response rate to therapy. An algorithm is provided on the management of asymptomatic individuals and the sequence used for chemotherapeutic intervention of symptomatic patients.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 First Street, SW, Rochester, MN, 55905, USA.
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19
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Simon L, Baron M, Leblond V. How we manage patients with Waldenström macroglobulinaemia. Br J Haematol 2018; 181:737-751. [PMID: 29637541 DOI: 10.1111/bjh.15202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Waldenström macroglobulinaemia (WM) is a rare, indolent B-cell lymphoproliferative disorder characterized by cellular involvement in bone marrow and monoclonal IgM production. Symptoms can be related to cytopenias, tumoural involvement, or IgM-related disorders. Somatic mutations in the MYD88 gene have been described in the majority of WM cases. The mutation is responsible for a gain-of-function and induces activation of nuclear factor-κB, for DNA transcription and cell survival. It seems that MYD88 mutation is associated with better prognosis and better response to some treatment. Treatments are started when WM is symptomatic, following systematic biological and morphological assessments. Therapeutic choice depends on age, frailty and urgent efficacy need. In first line, the majority of patients are treated with monoclonal anti-CD20 antibody-based regimens combined with cytotoxic chemotherapy. Rituximab, cyclophosphamide and dexamethasone remain the most commonly used regimen with good safety. Nevertheless, increasing numbers of new drugs are becoming available or are in development. Proteasome inhibitors, such as bortezomib or carfilzmib, showed good and rapid responses. Bruton tyrosine kinase (BTK) inhibitor demonstrated excellent results and is now available for relapse/refractory disease or as first line for some patients. This review highlights the diagnostic procedures and therapeutic approaches in WM.
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Affiliation(s)
- Laurence Simon
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
| | - Marine Baron
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
| | - Véronique Leblond
- Department of Haematology, APHP Hôpital Pitié-Salpétrière, Paris, France
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20
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21
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Treon SP, Castillo JJ, Hunter ZR, Merlini G. Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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22
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Mazzucchelli M, Frustaci AM, Deodato M, Cairoli R, Tedeschi A. Waldenstrom's Macroglobulinemia: An Update. Mediterr J Hematol Infect Dis 2018; 10:e2018004. [PMID: 29326801 PMCID: PMC5760071 DOI: 10.4084/mjhid.2018.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/13/2017] [Indexed: 12/19/2022] Open
Abstract
Waldenstrom Macroglobulinemia is a rare lymphoproliferative disorder with distinctive clinical features. Diagnostic and prognostic characterisation in WM significantly changed with the discovery of two molecular markers: MYD88 and CXCR4. Mutational status of these latter influences both clinical presentation and prognosis and demonstrated therapeutic implications. Treatment choice in Waldenstrom disease is strictly guided by patients age and characteristics, specific goals of therapy, the necessity for rapid disease control, the risk of treatment-related neuropathy, disease features, the risk of immunosuppression or secondary malignancies and potential for future autologous stem cell transplantation. The therapeutic landscape has expanded during the last years and the approval of ibrutinib, the first drug approved for Waldenstrom Macroglobulinemia, represents a significant step forward for a better management of the disease.
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Affiliation(s)
- Maddalena Mazzucchelli
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Anna Maria Frustaci
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Marina Deodato
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Roberto Cairoli
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
| | - Alessandra Tedeschi
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano
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23
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Abstract
Waldenstrom Macroglobulinemia is a rare lymphoproliferative disorder with distinctive clinical features. Diagnostic and prognostic characterisation in WM significantly changed with the discovery of two molecular markers: MYD88 and CXCR4. Mutational status of these latter influences both clinical presentation and prognosis and demonstrated therapeutic implications. Treatment choice in Waldenstrom disease is strictly guided by patients age and characteristics, specific goals of therapy, the necessity for rapid disease control, the risk of treatment-related neuropathy, disease features, the risk of immunosuppression or secondary malignancies and potential for future autologous stem cell transplantation. The therapeutic landscape has expanded during the last years and the approval of ibrutinib, the first drug approved for Waldenstrom Macroglobulinemia, represents a significant step forward for a better management of the disease.
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24
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Castillo JJ, Treon SP. Toward personalized treatment in Waldenström macroglobulinemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:365-370. [PMID: 29222280 PMCID: PMC6142554 DOI: 10.1182/asheducation-2017.1.365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Waldenström macroglobulinemia (WM) is a rare lymphoma with 1000 to 1500 new patients diagnosed per year in the United States. Patients with WM can experience prolonged survival times, which seem to have increased in the last decade, but relapse is inevitable. The identification of recurrent mutations in the MYD88 and CXCR4 genes has opened avenues of research to better understand and treat patients with WM. These developments are giving way to personalized treatment approaches for these patients, focusing on increasing depth and duration of response alongside lower toxicity rates. In the present document, we review the diagnostic differential, the clinical manifestations, and the pathological and genomic features of patients with WM. We also discuss the safety and efficacy data of alkylating agents, proteasome inhibitors, monoclonal antibodies, and Bruton tyrosine kinase inhibitors in patients with WM. Finally, we propose a genomically driven algorithm for the treatment of WM. The future of therapies for WM appears bright and hopeful, but we should be mindful of the cost-effectiveness and long-term toxicity of novel agents.
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Affiliation(s)
- Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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25
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Kapoor P, Ansell SM, Fonseca R, Chanan-Khan A, Kyle RA, Kumar SK, Mikhael JR, Witzig TE, Mauermann M, Dispenzieri A, Ailawadhi S, Stewart AK, Lacy MQ, Thompson CA, Buadi FK, Dingli D, Morice WG, Go RS, Jevremovic D, Sher T, King RL, Braggio E, Novak A, Roy V, Ketterling RP, Greipp PT, Grogan M, Micallef IN, Bergsagel PL, Colgan JP, Leung N, Gonsalves WI, Lin Y, Inwards DJ, Hayman SR, Nowakowski GS, Johnston PB, Russell SJ, Markovic SN, Zeldenrust SR, Hwa YL, Lust JA, Porrata LF, Habermann TM, Rajkumar SV, Gertz MA, Reeder CB. Diagnosis and Management of Waldenström Macroglobulinemia: Mayo Stratification of Macroglobulinemia and Risk-Adapted Therapy (mSMART) Guidelines 2016. JAMA Oncol 2017; 3:1257-1265. [PMID: 28056114 DOI: 10.1001/jamaoncol.2016.5763] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Waldenström macroglobulinemia (WM), an IgM-associated lymphoplasmacytic lymphoma, has witnessed several practice-altering advances in recent years. With availability of a wider array of therapies, the management strategies have become increasingly complex. Our multidisciplinary team appraised studies published or presented up to December 2015 to provide consensus recommendations for a risk-adapted approach to WM, using a grading system. Observations Waldenström macroglobulinemia remains a rare, incurable cancer, with a heterogeneous disease course. The major classes of effective agents in WM include monoclonal antibodies, alkylating agents, purine analogs, proteasome inhibitors, immunomodulatory drugs, and mammalian target of rapamycin inhibitors. However, the highest-quality evidence from rigorously conducted randomized clinical trials remains scant. Conclusions and Relevance Recognizing the paucity of data, we advocate participation in clinical trials, if available, at every stage of WM. Specific indications exist for initiation of therapy. Outside clinical trials, based on the synthesis of available evidence, we recommend bendamustine-rituximab as primary therapy for bulky disease, profound hematologic compromise, or constitutional symptoms attributable to WM. Dexamethasone-rituximab-cyclophosphamide is an alternative, particularly for nonbulky WM. Routine rituximab maintenance should be avoided. Plasma exchange should be promptly initiated before cytoreduction for hyperviscosity-related symptoms. Stem cell harvest for future use may be considered in first remission for patients 70 years or younger who are potential candidates for autologous stem cell transplantation. At relapse, retreatment with the original therapy is reasonable in patients with prior durable responses (time to next therapy ≥3 years) and good tolerability to previous regimen. Ibrutinib is efficacious in patients with relapsed or refractory disease harboring MYD88 L265P mutation. In the absence of neuropathy, a bortezomib-rituximab-based option is reasonable for relapsed or refractory disease. In select patients with chemosensitive disease, autologous stem cell transplantation should be considered at first or second relapse. Everolimus and purine analogs are suitable options for refractory or multiply relapsed WM. Our recommendations are periodically updated as new, clinically relevant information emerges.
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Affiliation(s)
| | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | | | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Joseph R Mikhael
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | | | | | | | | | - A Keith Stewart
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida
| | - Rebecca L King
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota
| | - Esteban Braggio
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | - Ann Novak
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - P Leif Bergsagel
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota.,Division of Nephrology, Mayo Clinic, Rochester, Minnesota
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | | | - Yi L Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Luis F Porrata
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, Arizona
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26
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Benevolo G, Nicolosi M, Santambrogio E, Vitolo U. Current options to manage Waldenström's macroglobulinemia. Expert Rev Hematol 2017; 10:637-647. [PMID: 28592170 DOI: 10.1080/17474086.2017.1339596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Waldenström's macroglobulinemia (WM) is a rare, incurable B-cell lymphoma, with a median survival of 5-10 years in symptomatic patients. There is no consensus on the standard of care and several agents are currently used in these patients. Areas covered: In this article, we will review the use of standard therapies and new drugs investigated such as monoclonal antibodies, proteasome inhibitors, immunomodulatory agents, Bruton's tyrosine kinase inhibitors and novel agents in early-stage development. Expert commentary: RCD (Rituximab/Cyclophosphamide/Dexamethasone) is an effective and safe treatment in first line in WM. BR (Bendamustine/Rituximab) or BRD (Bortezomib/Rituximab/Dexamethasone) provide durable responses, and are still indicated in most patients. Ibrutinib is a new option and it was approved as primary therapy and for relapse. Carfilzomib based therapy represents an emerging option for proteasome-inhibitor based therapy for WM. Despite encouraging results, WM remains an incurable disease; therefore, new treatment options are needed. For this reason, continued participation in clinical trials should be encouraged.
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Affiliation(s)
- Giulia Benevolo
- a Division of Hematology , AOU Città della Salute e della Scienza , Torino , Italy
| | - Maura Nicolosi
- a Division of Hematology , AOU Città della Salute e della Scienza , Torino , Italy
| | - Elisa Santambrogio
- a Division of Hematology , AOU Città della Salute e della Scienza , Torino , Italy
| | - Umberto Vitolo
- a Division of Hematology , AOU Città della Salute e della Scienza , Torino , Italy
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27
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Bennani NN, LaPlant BR, Ansell SM, Habermann TM, Inwards DJ, Micallef IN, Johnston PB, Porrata LF, Colgan JP, Markovic SN, Nowakowski GS, Macon WR, Reeder CB, Mikhael JR, Northfelt DW, Ghobrial IM, Witzig TE. Efficacy of the oral mTORC1 inhibitor everolimus in relapsed or refractory indolent lymphoma. Am J Hematol 2017; 92:448-453. [PMID: 28211162 DOI: 10.1002/ajh.24671] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/19/2022]
Abstract
Relapsed indolent lymphoma often becomes refractory to standard chemoimmunotherapy and requires new therapeutic strategies. Targeting the PI3K/mTOR pathway in several types of lymphoma has shown preclinical and clinical efficacy providing the rationale to test this strategy in the treatment of relapsed/refractory indolent lymphomas. We investigated in a phase II open label clinical trial the efficacy and safety of single agent everolimus, an inhibitor of mTORC1, in patients with relapsed/refractory indolent lymphomas. Eligible patients received oral everolimus 10 mg daily on a 28 day-cycle schedule. The primary endpoint was to evaluate the overall response rate (ORR) and safety of single-agent everolimus in this patient population. Fifty-five patients with indolent lymphoma were accrued. The median age was 67 years (range: 33-85) with a median of five prior therapies (range: 1-10). The ORR was 35% (19/55; 95% CI: 24-48%), with complete response unconfirmed in 4% (2/55), and partial response in 31% (17/55). The ORR was 61% (14/23) in the patients with FL. The median time to response was 2.3 months (range: 1.4-14.1), median duration of response of 11.5 months (95%-CI: 5.7-30.4), and a median progression-free survival of 7.2 months (95%-CI: 5.5-12.5). The most common toxicity was hematologic with grades 3-4 anemia, neutropenia, and thrombocytopenia documented in 15% (8/55), 22% (12/55), and 33% (18/55), respectively. There were no cases of febrile neutropenia, and eight patients discontinued therapy because of adverse events. Everolimus monotherapy is a valid therapeutic option in the relapsed and/or refractory indolent non-Hodgkin lymphoma patients and is well tolerated.
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Affiliation(s)
- N. Nora Bennani
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Betsy R. LaPlant
- Division of Biomedical Statistics and Bioinformatics, Department of Health Sciences ResearchMayo Clinic RochesterRochester Minnesota
| | - Stephen M. Ansell
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Thomas. M. Habermann
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - David J. Inwards
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Ivana N. Micallef
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Patrick B. Johnston
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Luis F. Porrata
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Joseph P. Colgan
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | - Svetomir N. Markovic
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
| | | | - William R. Macon
- Division of Hematopathology, Department of Laboratory Medicine and PathologyMayo Clinic RochesterRochester Minnesota
| | - Craig B. Reeder
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Joseph R. Mikhael
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Donald W. Northfelt
- Division of Hematology, Department of MedicineMayo Clinic ScottsdaleScottsdale Arizona
| | - Irene M. Ghobrial
- Dana Farber Cancer Institute, Harvard Medical SchoolBoston Massachusetts
| | - Thomas E. Witzig
- Division of Hematology, Department of MedicineMayo Clinic RochesterRochester Minnesota
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28
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Yun S, Johnson AC, Okolo ON, Arnold SJ, McBride A, Zhang L, Baz RC, Anwer F. Waldenström Macroglobulinemia: Review of Pathogenesis and Management. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2017; 17:252-262. [PMID: 28366781 PMCID: PMC5413391 DOI: 10.1016/j.clml.2017.02.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 11/20/2022]
Abstract
Waldenström macroglobulinemia (WM) is a low-grade B-cell clonal disorder characterized by lymphoplasmacytic bone marrow involvement associated with monoclonal immunoglobulin M. Although WM remains to be an incurable disease with a heterogeneous clinical course, the recent discovery of mutations in the MYD88 and CXCR4 genes further enhanced our understanding of its pathogenesis. Development of new therapies including monoclonal antibodies, proteasome inhibitors, and Bruton tyrosine kinase inhibitors have made the management of WM increasingly complex. Treatment should be tailored to the individual patient while considering many clinical factors. The clinical outcomes are expected to continue to improve, given the emergence of novel therapeutics and better understanding of the underlying pathogenesis.
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Affiliation(s)
- Seongseok Yun
- Department of Medicine, University of Arizona, Tucson, AZ; Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | | | - Stacy J Arnold
- Division of Pathology, Department of Medicine, University of Arizona, Tucson, AZ
| | - Ali McBride
- College of Pharmacy, University of Arizona, Tucson, AZ
| | - Ling Zhang
- Department of Hematopathology and Laboratory Medicine, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Rachid C Baz
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Faiz Anwer
- Division of Hematology, Oncology, Blood, and Marrow Transplantation, Department of Medicine, University of Arizona, Tucson, AZ.
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29
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Abeykoon JP, Yanamandra U, Kapoor P. New developments in the management of Waldenström macroglobulinemia. Cancer Manag Res 2017; 9:73-83. [PMID: 28331368 PMCID: PMC5354523 DOI: 10.2147/cmar.s94059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Waldenström macroglobulinemia (WM) is a rare, immunoglobulin M -associated lymphoplasmacytic lymphoma. With the recent discoveries of CXCR warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) and MYD88 mutations, our understanding of the biology of WM has expanded substantially. While WM still remains incurable, the field is rapidly evolving, and a number of promising agents with significant activity in this malignancy are being evaluated currently. In this review, we discuss the new developments that have occurred in WM over the past 15 years, with a focus on the role of ibrutinib, an oral Bruton's tyrosine kinase inhibitor that has recently been approved for WM in the United States, Europe, and Canada.
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Affiliation(s)
| | - Uday Yanamandra
- Department of Hematology and Stem Cell Transplant, Army Hospital (Research & Referral), Delhi, India
| | - Prashant Kapoor
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Gertz MA. Waldenström macroglobulinemia: 2017 update on diagnosis, risk stratification, and management. Am J Hematol 2017; 92:209-217. [PMID: 28094456 DOI: 10.1002/ajh.24557] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 12/26/2022]
Abstract
Disease Overview: Waldenström macroglobulinemia (WM) is a lymphoplasmacytic lymphoma with immunoglobulin M (IgM) monoclonal protein. Clinical features include anemia, thrombocytopenia, hepatosplenomegaly, lymphadenopathy, and rarely hyperviscosity. DIAGNOSIS Presence of IgM monoclonal protein associated with ≥10% clonal lymphoplasmacytic cells in bone marrow confirms the diagnosis. The L265P mutation in MYD88 is detectable in more than 90% of patients. Risk Stratification: Age, hemoglobin level, platelet count, β2 microglobulin, and monoclonal IgM concentrations are characteristics required for prognosis. Risk-Adapted Therapy: Not all patients who fulfill WM criteria require therapy; these patients can be observed until symptoms develop. Rituximab-based therapy is used in virtually all U.S. patients with WM and can be combined with bendamustine, an alkylating agent, or a proteosome inhibitor. Purine nucleoside analogues are widely used in Europe. The preferred Mayo Clinic nonstudy therapeutic induction is rituximab and bendamustine. Potential for stem cell transplantation should be considered in induction therapy selection. Management of Refractory Disease: Bortezomib, fludarabine, thalidomide, everolimus, ibrutinib, carfilzomib, lenalidomide, and bendamustine have all been shown to have activity in WM. Given WM's natural history, reduction of complications will be a priority for future treatment trials. Am. J. Hematol. 92:209-217, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Calimeri T, Ferreri AJM. m-TOR inhibitors and their potential role in haematological malignancies. Br J Haematol 2017; 177:684-702. [PMID: 28146265 DOI: 10.1111/bjh.14529] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/28/2016] [Indexed: 12/22/2022]
Abstract
It is widely demonstrated that the PI3K-AKT-mTOR signalling is critical in normal myeloid and lymphoid development and function. Thus, it is not strange that this pathway is often deregulated in haematological tumours, providing a strong preclinical rationale for the use of drugs targeting the PI3K-AKT-mTOR axis in haematological malignancies. The main focus of this review is to examine the mammalian target of rapamycin (mTOR, also termed mechanistic target of rapamycin [MTOR]) signalling pathways and to provide a brief overview of rapalogs and second-generation mTOR inhibitors used to target its aberrant activation in cancer treatment. We will also discuss the results obtained with the use of these agents in patients with acute leukaemia, Hodgkin lymphoma, non-Hodgkin lymphomas, multiple myeloma and Waldenström macroglobulinaemia. Ongoing clinical trials in haematological malignancies that are investigating first- and second-generation mTOR inhibitors as single agents and as components of combination regimens are also presented.
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Affiliation(s)
- Teresa Calimeri
- Unit of Lymphoid Malignancies, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Andrés J M Ferreri
- Unit of Lymphoid Malignancies, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milano, Italy
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Gavriatopoulou M, Terpos E, Kastritis E, Dimopoulos MA. Current treatment options and investigational drugs for Waldenstrom’s Macroglobulinemia. Expert Opin Investig Drugs 2017; 26:197-205. [DOI: 10.1080/13543784.2017.1275561] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Alexandra General Hospital, Athens, Greece
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Treon SP, Meid K, Tripsas C, Heffner LT, Eradat H, Badros AZ, Xu L, Hunter ZR, Yang G, Patterson CJ, Gustine J, Castillo JJ, Matous J, Ghobrial IM. Prospective, Multicenter Clinical Trial of Everolimus as Primary Therapy in Waldenstrom Macroglobulinemia (WMCTG 09-214). Clin Cancer Res 2016; 23:2400-2404. [PMID: 27836860 DOI: 10.1158/1078-0432.ccr-16-1918] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/05/2016] [Accepted: 10/24/2016] [Indexed: 11/16/2022]
Abstract
Purpose: Everolimus inhibits mTOR, a component of PI3K/AKT prosurvival signaling triggered by MYD88 and CXCR4-activating mutations in Waldenstrom macroglobulinemia.Experimental design: We evaluated everolimus in a prospective, multicenter study of 33 symptomatic, previously untreated Waldenstrom macroglobulinemia patients. Intended therapy consisted of everolimus (10 mg/day) until progression or unacceptable toxicity. Dose deescalation was permitted. The study was registered at www.clinicaltrials.gov (NCT00976248).Results: At best response, median serum IgM levels declined from 4,440 to 1,360 mg/dL (P < 0.0001), median hemoglobin rose from 10.8 to 12 g/dL (P = 0.001), and median bone marrow disease burden declined from 75% to 52.5% in serially biopsied patients. The ORR and major response rates were 72.7% and 60.6%, respectively. Among genotyped patients, nonresponders associated with wild-type MYD88 and mutated CXCR4 status. Median time to response was 4 weeks. Discordance between serum IgM levels and bone marrow disease burden was remarkable. With a median follow-up of 13.1 (range, 1.6-64.6 months), the median time to progression was 21 months for all patients and 33 months for major responders. Discontinuation of everolimus led to rapid serum IgM rebound in 7 patients and symptomatic hyperviscosity in 2 patients. Toxicity led to treatment discontinuation in 27% of patients, including 18% for pneumonitis.Conclusions: Everolimus is active in previously untreated Waldenstrom macroglobulinemia. IgM discordance is common, and treatment cessation can often lead to rapid serum IgM rebound. Pneumonitis also appears more pronounced in untreated versus previously treated Waldenstrom macroglobulinemia patients. The risks and benefits of everolimus should be carefully weighed against other primary Waldenstrom macroglobulinemia therapy options. Clin Cancer Res; 23(10); 2400-4. ©2016 AACR.
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Affiliation(s)
- Steven P Treon
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts.
| | - Kirsten Meid
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Christina Tripsas
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Leonard T Heffner
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Herbert Eradat
- Jonsson Comprehensive Cancer Center, UCLA School of Medicine, Los Angeles, California
| | - Ashraf Z Badros
- Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Lian Xu
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Zachary R Hunter
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Guang Yang
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Christopher J Patterson
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Joshua Gustine
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | - Jorge J Castillo
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
| | | | - Irene M Ghobrial
- Bing Center for Waldenstrom's Macroglobulinemia at the Dana-Farber Cancer Institute; and Harvard Medical School, Boston, Massachusetts
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Kastritis E, Dimopoulos MA. Current therapy guidelines for Waldenstrom's macroglobulinaemia. Best Pract Res Clin Haematol 2016; 29:194-205. [PMID: 27825466 DOI: 10.1016/j.beha.2016.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 08/30/2016] [Indexed: 12/20/2022]
Abstract
Waldenstrom's macroglobulinaemia (WM) is a B-cell neoplasm in which bone marrow is infiltrated by lymphoplasmacytic cells that secrete monoclonal immunoglobulin M (IgM). More than a decade ago, specific criteria were agreed to define diagnosis and symptomatic disease requiring therapy; however, treatment recommendations change as new options emerge. Treatment decisions consider specific disease characteristics (burden of disease, IgM levels, presence of cytopenias) and patient characteristics (age, comorbidities, toxicity). Recently, the impact of specific mutations (in MYD88 and CXCR4) in response to specific therapies has been reported, and this may affect treatment decisions in the future. Chemo-immunotherapy combinations based on rituximab with cyclophosphamide/dexamethasone, bendamustine or bortezomib/dexamethasone are indicated for most patients. The BTK inhibitor ibrutinib was recently approved for patients with WM, and is a new option for selected newly diagnosed or relapsing patients. New B-cell receptor inhibitors, second-generation proteasome inhibitors and mammalian target of rapamycin inhibitors are promising; however, more data are needed from high-quality clinical trials.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Chakraborty R, Muchtar E, Gertz MA. The role of stem cell transplantation in Waldenstrom's macroglobulinemia. Best Pract Res Clin Haematol 2016; 29:229-240. [PMID: 27825469 DOI: 10.1016/j.beha.2016.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/29/2016] [Accepted: 08/30/2016] [Indexed: 12/22/2022]
Abstract
Waldenstrom's macroglobulinemia (WM) is an indolent B-cell lymphoma, which is highly chemosensitive, with an overall response rate over 90% to novel agents. However, most patients eventually relapse after response to first-line chemotherapy, necessitating further treatment. The possibility of long-lasting remission after high-dose cytotoxic chemotherapy followed by stem cell rescue is high in WM due to the chemosensitive nature of the disease and lower proliferative activity compared to multiple myeloma. In this paper, we have reviewed current evidence on autologous (auto-) and allogeneic (allo-) stem cell transplantation (SCT) in WM. Auto-SCT can be safely performed in WM and is recommended as second-line treatment or beyond in eligible patients. It is associated with extremely low transplant-related mortality. Allo-SCT is effective in WM with incremental benefit due to graft-versus-WM effect, but is associated with high non-relapse mortality of 30%, hence should be preferably considered investigational as part of clinical trials in selected patients who have exhausted other treatment options.
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Affiliation(s)
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Treatment recommendations from the Eighth International Workshop on Waldenström's Macroglobulinemia. Blood 2016; 128:1321-8. [PMID: 27432877 DOI: 10.1182/blood-2016-04-711234] [Citation(s) in RCA: 139] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/11/2016] [Indexed: 11/20/2022] Open
Abstract
Waldenström macroglobulinemia (WM) is a distinct B-cell lymphoproliferative disorder for which clearly defined criteria for the diagnosis, initiation of therapy, and treatment strategy have been proposed as part of the consensus panels of the International Workshop on Waldenström's Macroglobulinemia (IWWM). At IWWM-8, a task force for treatment recommendations was impanelled to review recently published and ongoing clinical trial data as well as the impact of new mutations (MYD88 and CXCR4) on treatment decisions, indications for B-cell receptor and proteasome inhibitors, and future clinical trial initiatives for WM patients. The panel concluded that therapeutic strategies in WM should be based on individual patient and disease characteristics. Chemoimmunotherapy combinations with rituximab and cyclophosphamide-dexamethasone, bendamustine, or bortezomib-dexamethasone provide durable responses and are still indicated in most patients. Approval of the BTK inhibitor ibrutinib in the United States and Europe represents a novel and effective treatment option for both treatment-naive and relapsing patients. Other B-cell receptor inhibitors, second-generation proteasome inhibitors (eg, carfilzomib), and mammalian target of rapamycin inhibitors are promising and may increase future treatment options. Active enrollment in clinical trials whenever possible was endorsed by the panel for most patients with WM.
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37
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Ghobrial IM, Siegel DS, Vij R, Berdeja JG, Richardson PG, Neuwirth R, Patel CG, Zohren F, Wolf JL. TAK-228 (formerly MLN0128), an investigational oral dual TORC1/2 inhibitor: A phase I dose escalation study in patients with relapsed or refractory multiple myeloma, non-Hodgkin lymphoma, or Waldenström's macroglobulinemia. Am J Hematol 2016; 91:400-5. [PMID: 26800393 DOI: 10.1002/ajh.24300] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 12/13/2022]
Abstract
The PI3K/AKT/mTOR signaling pathways are frequently dysregulated in multiple human cancers, including multiple myeloma (MM), non-Hodgkin lymphoma (NHL), and Waldenström's macroglobulinemia (WM). This was the first clinical study to evaluate the safety, tolerability, maximal-tolerated dose (MTD), dose-limiting toxicity (DLT), pharmacokinetics, and preliminary clinical activity of TAK-228, an oral TORC1/2 inhibitor, in patients with MM, NHL, or WM. Thirty-nine patients received TAK-228 once daily (QD) at 2, 4, 6, or 7 mg, or QD for 3 days on and 4 days off each week (QDx3d QW) at 9 or 12 mg, in 28-day cycles. The overall median age was 61.0 years (range 46-85); 31 patients had MM, four NHL, and four WM. Cycle 1 DLTs occurred in five QD patients (stomatitis, urticaria, blood creatinine elevation, fatigue, and nausea and vomiting) and four QDx3d QW patients (erythematous rash, fatigue, asthenia, mucosal inflammation, and thrombocytopenia). The MTDs were determined to be 4 mg QD and 9 mg QDx3d QW. Thirty-six patients (92%) reported at least one drug-related toxicity; the most common grade ≥3 drug-related toxicities were thrombocytopenia (15%), fatigue (10%), and neutropenia (5%). TAK-228 exhibited a dose-dependent increase in plasma exposure and no appreciable accumulation with repeat dosing; mean plasma elimination half-life was 6-8 hr. Of the 33 response-evaluable patients, one MM patient had a minimal response, one WM patient achieved partial response, one WM patient had a minor response, and 18 patients (14 MM, two NHL, and two WM) had stable disease. These findings encourage further studies including combination strategies.
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Affiliation(s)
- Irene M. Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute; Boston Massachusetts
| | - David S. Siegel
- John Theurer Cancer Center at Hackensack University Medical Center; Hackensack New Jersey
| | - Ravi Vij
- Division of Hematology and Oncology, Washington University School of Medicine; St. Louis Missouri
| | | | - Paul G. Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute; Boston Massachusetts
| | - Rachel Neuwirth
- Global Biostatistics, Millennium Pharmaceuticals, Inc, Cambridge, Massachusetts, USA, a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited
| | - Chirag G. Patel
- Clinical Pharmacology, Millennium Pharmaceuticals, Inc; Cambridge Massachusetts USA, a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited
| | - Fabian Zohren
- Oncology Clinical Research, Millennium Pharmaceuticals, Inc; Cambridge Massachusetts USA, a Wholly Owned Subsidiary of Takeda Pharmaceutical Company Limited
| | - Jeffrey L. Wolf
- Department of Medicine; University of California San Francisco; San Francisco California
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Speed bumps on the road to a chemotherapy-free world for lymphoma patients. Blood 2016; 128:325-30. [PMID: 27222479 DOI: 10.1182/blood-2016-04-709477] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/21/2016] [Indexed: 12/26/2022] Open
Abstract
With the increasing number of targeted agents for the treatment of patients with lymphoid malignancies comes the promise of safe and effective chemotherapy-free treatment strategies. A number of single agents, such as ibrutinib and idelalisib, have demonstrated impressive efficacy with a favorable toxicity profile. The observations that most responses are, however, partial and treatment duration is indefinite have stimulated interest in combinations of these agents with chemotherapy as well as with each other. Despite the promise of this approach, several recent trials of combinations of agents have been terminated as the result of life-threatening and fatal complications. Such outcomes have generated a cautionary note of the potential for unforeseen adverse effects that challenge drug development and mitigate against the empiric combination of such drugs outside of a clinical trial setting.
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Waldenstrom Macroglobulinemia: Familial Predisposition and the Role of Genomics in Prognosis and Treatment Selection. Curr Treat Options Oncol 2016; 17:16. [DOI: 10.1007/s11864-016-0391-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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40
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Dimopoulos MA, Kastritis E, Ghobrial IM. Waldenström's macroglobulinemia: a clinical perspective in the era of novel therapeutics. Ann Oncol 2016; 27:233-40. [PMID: 26598544 PMCID: PMC4722893 DOI: 10.1093/annonc/mdv572] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/09/2015] [Accepted: 11/16/2015] [Indexed: 12/20/2022] Open
Abstract
Waldenström's macroglobulinemia (WM) is a rare, low-grade malignancy with no established standard of care. Rituximab regimens are most commonly used, supported by their efficacy in hematologic malignancies, including WM. A growing number of investigational regimens for WM have been evaluated in phase II clinical trials, including single-agent and combination strategies that include newer-generation monoclonal antibodies (ofatumumab and alemtuzumab), proteasome inhibitors (bortezomib and carfilzomib), immunomodulatory agents (thalidomide and lenalidomide), phosphoinositide 3-kinase/protein kinase B (Akt)/mammalian target of rapamycin pathway inhibitors (everolimus and perifosene), a Bruton's tyrosine kinase inhibitor (ibrutinib), and a histone deacetylase inhibitor (panobinostat). Other novel agents are in early-stage development for WM. International treatment guidelines for WM suggest suitable regimens in the newly diagnosed and relapsed/refractory settings, in accordance with patient age, disease presentation, and efficacy and safety profiles of particular drugs. These factors must be considered when choosing appropriate therapy for individual patients with WM, to maximize response and prolong survival, while minimizing the risk of adverse events. This review article provides a clinical perspective of the modern management of patients with WM, in the context of available trial data for novel regimens and recently updated treatment guidelines.
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Affiliation(s)
- M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - I M Ghobrial
- Medical Oncology, Dana Farber Cancer Center, Boston, MA, USA
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41
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Abstract
Waldenström macroglobulinemia (WM) is a rare, indolent, and monoclonal immunoglobulin M-associated lymphoplasmacytic disorder with unique clinicopathologic characteristics. Over the past decade, remarkable progress has occurred on both the diagnostic and therapeutic fronts in WM. A deeper understanding of the disease biology emanates from the seminal discoveries of myeloid differentiation primary response 88 (MYD88) L265P somatic mutation in the vast majority of cases and C-X-C chemokine receptor, type 4, mutations in about a third of patients. Although WM remains an incurable malignancy, and the indications to initiate treatment are largely unchanged, the therapeutic armamentarium continues to expand. Acknowledging the paucity of high-level evidence from large randomized controlled trials, herein, we evaluate the genomic aberrations and provide a strategic framework for the management in the frontline as well as the relapsed/refractory settings of symptomatic WM.
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Zent CS, Bowen DA, Conte MJ, LaPlant BR, Call TG. Treatment of relapsed/refractory chronic lymphocytic leukemia/small lymphocytic lymphoma with everolimus (RAD001) and alemtuzumab: a Phase I/II study. Leuk Lymphoma 2015; 57:1585-91. [DOI: 10.3109/10428194.2015.1113280] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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43
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Fouquet G, Guidez S, Petillon MO, Louni C, Ohyba B, Dib M, Poulain S, Herbaux C, Martin A, Thielemans B, Brice P, Choquet S, Bakala J, Bories C, Demarquette H, Nudel M, Tournilhac O, Arnulf B, LeGouill S, Morel P, Banos A, Karlin L, Salles G, Leblond V, Leleu X. Lenalidomide is safe and active in Waldenström macroglobulinemia. Am J Hematol 2015; 90:1055-9. [PMID: 26284823 DOI: 10.1002/ajh.24175] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/11/2015] [Accepted: 08/12/2015] [Indexed: 11/10/2022]
Abstract
Lenalidomide is manageable and effective in multiple myeloma, particularly in elderly patients. Surprisingly, the combination of lenalidomide with rituximab produced clinically significant anemia at 25 mg/day for 21/28 days, the highest possible dose, in Waldenström's Macroglobulinemia (WM). We aimed to determine the maximum tolerated dose (MTD) of single agent lenalidomide and determine its impact on WM. RV-WM-0426 is a multicenter dose escalation open label phase 1/2 study of lenalidomide in relapsed/refractory WM (RRWM). Lenalidomide was given orally 21/28 days per cycle for 1 year, at escalated dose of 15 to 20 mg during phase 1 to determine the MTD; the phase 2 part was conducted at the MTD. Seventeen RRWM patients were included. The MTD was established at 15 mg/day 21/28. By ITT analysis, the overall response rate was 29%. With a median follow-up of 36 months, median TTP was 16 months (95% CI 5.5-26), the 5-year OS was 91%. The most frequent adverse events ≥ grade 3 at 15 mg were 14% anemia and 43% neutropenia. The MTD of lenalidomide is 15 mg/day 21/28 days in RRWM. Lenalidomide is active in the treatment of RRWM and the safety profile appears manageable. Future studies may look into combinations of lenalidomide and continuous dosing.
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Affiliation(s)
| | | | | | - Chanaz Louni
- Département De Recherche Clinique, CHRU; Lille France
| | - Bella Ohyba
- Département De Recherche Clinique, CHRU; Lille France
| | - Malek Dib
- Département De Recherche Clinique, CHRU; Lille France
| | | | | | - Audrey Martin
- Hématologie, Hôpital Côte De Nacre, CHU Caen; France
| | | | - Pauline Brice
- Hématologie, Hôpital Pitié-Salpêtrière, APHP; Paris France
| | - Sylvain Choquet
- Institut Universitaire D'hématologie, APHP Saint Louis; Paris EA3963 France
| | | | - Claire Bories
- Maladies Du Sang, Hôpital Huriez, CHRU; Lille France
| | | | - Morgane Nudel
- Maladies Du Sang, Hôpital Huriez, CHRU; Lille France
| | | | | | | | | | | | | | | | | | - Xavier Leleu
- Maladies Du Sang, Hôpital Huriez, CHRU; Lille France
- U837 Inserm, IRCL, CHRU; Lille France
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Gayko U, Fung M, Clow F, Sun S, Faust E, Price S, James D, Doyle M, Bari S, Zhuang SH. Development of the Bruton's tyrosine kinase inhibitor ibrutinib for B cell malignancies. Ann N Y Acad Sci 2015; 1358:82-94. [PMID: 26348626 DOI: 10.1111/nyas.12878] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Ibrutinib is a first-in-class oral covalent inhibitor of Bruton's tyrosine kinase that has demonstrated clinical benefit for many patients with B cell malignancies. Positive results in initial trials led the U.S. Food and Drug Administration to grant ibrutinib three breakthrough therapy designations for mantle cell lymphoma (MCL), del17p chronic lymphocytic leukemia (CLL), and Waldenström's macroglobulinemia (WM). Ibrutinib was approved for these three cancers within 14 months of the original U.S. approval. Additionally, ibrutinib is approved for patient subsets with MCL and/or CLL in >45 other countries. Via a unique mechanism of action, ibrutinib inhibits B cell signaling pathways that regulate the survival, proliferation, adhesion, and homing of cancerous cells. This marks a paradigm shift from the conventional cytotoxic chemotherapy approach to treating B cell malignancies. Ibrutinib continues to be evaluated across a range of B cell malignancies, either as single-agent therapy or in combination with other therapies, and continues to transform the lives of these patients.
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Affiliation(s)
- Urte Gayko
- Pharmacyclics, Inc, Sunnyvale, California
| | - Mann Fung
- Janssen Research & Development, LLC, Raritan, New Jersey
| | - Fong Clow
- Pharmacyclics, Inc, Sunnyvale, California
| | - Steven Sun
- Janssen Research & Development, LLC, Raritan, New Jersey
| | | | - Samiyeh Price
- Janssen Research & Development, LLC, Raritan, New Jersey
| | | | - Margaret Doyle
- Janssen Research & Development, LLC, Raritan, New Jersey
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Chakraborty R, Kapoor P, Ansell SM, Gertz MA. Emerging therapeutic options for Waldenström macroglobulinemia/lymphoplasmacytic lymphoma. Expert Rev Anticancer Ther 2015. [PMID: 26196236 DOI: 10.1586/14737140.2015.1071668] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Lymphoplasmacytic lymphoma is an indolent B-cell, non-Hodgkin lymphoma (NHL), the majority of which are characterized by production of a monoclonal immunoglobulin M (IgM) protein and are known as Waldenström macroglobulinemia. Identification of highly recurrent activating somatic mutation in MYD88 has improved our understanding of the pathogenesis of Waldenström macroglobulinemia and has therapeutic implications. Here, we review novel therapeutic agents in Waldenström macroglobulinemia/lymphoplasmacytic lymphoma, which have emerged in the past decade and discuss their comparative efficacy and safety, with emphasis on a Bruton's tyrosine kinase (BTK) inhibitor, which has been recently approved by the US FDA, specifically for Waldenström macroglobulinemia/lymphoplasmacytic lymphoma. Future research should focus on identifying targeted agents against activating mutations and long-term data for currently available novel agents should be critically evaluated, both in treatment-naïve and in relapsed/refractory settings.
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Witzig TE, Reeder C, Han JJ, LaPlant B, Stenson M, Tun HW, Macon W, Ansell SM, Habermann TM, Inwards DJ, Micallef IN, Johnston PB, Porrata LF, Colgan JP, Markovic S, Nowakowski GS, Gupta M. The mTORC1 inhibitor everolimus has antitumor activity in vitro and produces tumor responses in patients with relapsed T-cell lymphoma. Blood 2015; 126:328-35. [PMID: 25921059 PMCID: PMC4504947 DOI: 10.1182/blood-2015-02-629543] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/20/2015] [Indexed: 12/17/2022] Open
Abstract
Everolimus is an oral agent that targets the mammalian target of rapamycin (mTOR) pathway. This study investigated mTOR pathway activation in T-cell lymphoma (TCL) cell lines and assessed antitumor activity in patients with relapsed/refractory TCL in a phase 2 trial. The mTOR pathway was activated in all 6 TCL cell lines tested and everolimus strongly inhibited malignant T-cell proliferation with minimal cytotoxic effects. Everolimus completely inhibited phosphorylation of ribosomal S6, a raptor/mTOR complex 1 (mTORC1) target, without a compensatory activation of the rictor/mTORC2 target Akt (S475). In the clinical trial, 16 patients with relapsed TCL were enrolled and received everolimus 10 mg by mouth daily. Seven patients (44%) had cutaneous (all mycosis fungoides); 4 (25%) had peripheral T cell not otherwise specified; 2 (13%) had anaplastic large cell; and 1 each had extranodal natural killer/T cell, angioimmunoblastic, and precursor T-lymphoblastic leukemia/lymphoma types. The overall response rate was 44% (7/16; 95% confidence interval [CI]: 20% to 70%). The median progression-free survival was 4.1 months (95% CI, 1.5-6.5) and the median overall survival was 10.2 months (95% CI, 2.6-44.3). The median duration of response for the 7 responders was 8.5 months (95% CI, 1.0 to not reached). These studies indicate that everolimus has antitumor activity and provide proof-of-concept that targeting the mTORC1 pathway in TCL is clinically relevant. This trial was registered at www.clinicaltrials.gov as #NCT00436618.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Animals
- Apoptosis/drug effects
- Blotting, Western
- Cell Proliferation/drug effects
- Cytokines/blood
- Everolimus
- Female
- Flow Cytometry
- Humans
- Immunosuppressive Agents/pharmacology
- In Vitro Techniques
- Lymphoma, T-Cell/drug therapy
- Lymphoma, T-Cell/metabolism
- Lymphoma, T-Cell/mortality
- Lymphoma, T-Cell/pathology
- Male
- Mechanistic Target of Rapamycin Complex 1
- Mechanistic Target of Rapamycin Complex 2
- Middle Aged
- Multiprotein Complexes/antagonists & inhibitors
- Multiprotein Complexes/metabolism
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/metabolism
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Phosphorylation
- Prognosis
- Sirolimus/analogs & derivatives
- Sirolimus/pharmacology
- Survival Rate
- TOR Serine-Threonine Kinases/antagonists & inhibitors
- TOR Serine-Threonine Kinases/metabolism
- Tumor Cells, Cultured
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Affiliation(s)
- Thomas E Witzig
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Craig Reeder
- Division of Hematology, Department of Medicine, Mayo Clinic Scottsdale, Scottsdale, AZ
| | - Jing Jing Han
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Betsy LaPlant
- Division of Biomedical Statistics and Bioinformatics, Department of Health Sciences Research, Mayo Clinic Rochester, Rochester, MN
| | - Mary Stenson
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Han W Tun
- Division of Hematology, Department of Medicine, Mayo Clinic Jacksonville, Jacksonville, FL; and
| | - William Macon
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, MN
| | - Stephen M Ansell
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Thomas M Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - David J Inwards
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Ivana N Micallef
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Patrick B Johnston
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Luis F Porrata
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Joseph P Colgan
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Svetomir Markovic
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Grzegorz S Nowakowski
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Mamta Gupta
- Division of Hematology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN
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Phase I/II trial of everolimus in combination with bortezomib and rituximab (RVR) in relapsed/refractory Waldenstrom macroglobulinemia. Leukemia 2015; 29:2338-46. [DOI: 10.1038/leu.2015.164] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/07/2015] [Accepted: 05/15/2015] [Indexed: 12/17/2022]
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Leblebjian H, Noonan K, Paba-Prada C, Treon SP, Castillo JJ, Ghobrial IM. Cyclophosphamide, bortezomib, and dexamethasone combination in waldenstrom macroglobulinemia. Am J Hematol 2015; 90:E122-3. [PMID: 25703132 DOI: 10.1002/ajh.23985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/17/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Houry Leblebjian
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Kimberly Noonan
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Claudia Paba-Prada
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Steven P. Treon
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Jorge J. Castillo
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Irene M. Ghobrial
- Harvard Medical School; Dana-Farber Cancer Institute; Boston Massachusetts
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Abstract
Waldenström macroglobulinemia (WM) is a B-cell neoplasm manifested by the accumulation of clonal immunoglobulin (Ig)M-secreting lymphoplasmacytic cells. MYD88 and CXCR4 warts, hypogammaglobulinemia, infections, myelokathexis syndrome-like somatic mutations are present in >90% and 30% to 35% of WM patients, respectively, and impact disease presentation, treatment outcome, and overall survival. Familial predisposition is common in WM. Asymptomatic patients should be observed. Patients with disease-related hemoglobin <10 g/L, platelets <100 × 10(9)/L, bulky adenopathy and/or organomegaly, symptomatic hyperviscosity, peripheral neuropathy, amyloidosis, cryoglobulinemia, cold-agglutinin disease, or transformed disease should be considered for therapy. Plasmapheresis should be used for patients with symptomatic hyperviscosity and before rituximab for those with high serum IgM levels to preempt a symptomatic IgM flare. Treatment choice should take into account specific goals of therapy, necessity for rapid disease control, risk of treatment-related neuropathy, immunosuppression and secondary malignancies, and planning for future autologous stem cell transplantation. Frontline treatments include rituximab alone or rituximab combined with alkylators (bendamustine and cyclophosphamide), proteasome inhibitors (bortezomib and carfilzomib), nucleoside analogs (fludarabine and cladribine), and ibrutinib. In the salvage setting, an alternative frontline regimen, ibrutinib, everolimus, or stem cell transplantation can be considered. Investigational therapies under development for WM include agents that target MYD88, CXCR4, BCL2, and CD27/CD70 signaling, novel proteasome inhibitors, and chimeric antigen receptor-modified T-cell therapy.
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Krem MM, Gopal AK. New targeted therapies for indolent B-cell malignancies in older patients. Am Soc Clin Oncol Educ Book 2015:e365-74. [PMID: 25993198 DOI: 10.14694/edbook_am.2015.35.e365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Molecularly targeted agents have become an established component of the treatment of indolent B-cell malignancies (iNHL). iNHL disproportionately affects older adults, so treatments that have excellent tolerability and efficacy across multiple lines of therapy are in demand. The numbers and classes of targeted therapies for iNHL have proliferated rapidly in recent years; classes of agents that show promise for older patients with iNHL include anti-CD20 antibodies, phosphatidyl-3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) signaling pathway inhibitors, immunomodulators, proteasome inhibitors, epigenetic modulators, and immunotherapies. Here, we review the proposed mechanisms of action, efficacy, and tolerability of novel agents for iNHL, with an emphasis on their applicability to older patients.
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Affiliation(s)
- Maxwell M Krem
- From the University of Louisville Brown Cancer Center, Louisville, KY; Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ajay K Gopal
- From the University of Louisville Brown Cancer Center, Louisville, KY; Fred Hutchinson Cancer Research Center, Seattle, WA
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