SAFETY AND EFFICACY OF THE PD-L1 INHIBITOR DURVALUMAB WITH R-CHOP OR R2 -CHOP IN SUBJECTS WITH PREVIOUSLY UNTREATED, HIGH-RISK DLBCL

Immunotherapy for Diffuse Large B-Cell Lymphoma: Current Landscape and Future Directions

Simple Summary

Immunotherapy has played a pivotal role in the management of relapsed DLBCL. Stem cell transplant and CAR T-cell therapy are curative treatment modalities for relapsed disease. Despite this, a subset of patients continues to progress, and their outcomes remain dismal. Newer therapeutic options to optimize outcomes as well as minimize toxicity are warranted.

Abstract

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease. B-cell receptor (BCR) pathway is essential for malignant B-cell growth, survival, and proliferation. Various immune cells, including T-cells and macrophages in the tumor microenvironment (TME) contribute to tumor cell survival and pathogenesis of chemo-resistance. The presence of many targets on the malignant B-cells and in the TME has led to emergence of novel therapeutic agents. Stem cell transplant is the oldest treatment modality leveraging immune system in DLBCL. Subsequently, CD20 targeting monoclonal antibody and chimeric antigen receptor (CAR) T-cell therapy changed the treatment landscape of DLBCL. Recently, multiple novel immunotherapeutic agents have been added in the armamentarium for the management of DLBCL, and many are under development. In this review article, we will review latest updates of immunotherapeutic agents in the management of DLBCL.

Why R-CHOP + X is not enough: lessons learned and next steps in the mission to improve frontline therapy for diffuse large B-cell lymphoma

Two-thirds of newly diagnosed cases of diffuse large B-cell lymphoma (DLBCL) are cured with R-CHOP, an immunochemotherapy regimen that has been the standard of care for almost two decades. Ongoing molecular characterization of DLBCL has revealed a heterogeneous disease comprised of multiple subtypes based on putative cell of origin or somatic mutations with unique oncogenic signaling pathways. The door has been opened to the use of novel agents that target the specific molecular vulnerabilities of DLBCL, but despite this, multiple randomized studies have not identified a suitable drug 'X' to combine with R-CHOP. This report will review recent attempts to add individual novel agents to R-CHOP in the mission to improve frontline treatment for DLBCL and discuss promising ongoing studies. It will offer potential strategies to explore when designing future clinical trials, including exploiting synergy between multiple novel agents.

Current Clinical Applications and Future Perspectives of Immune Checkpoint Inhibitors in Non-Hodgkin Lymphoma

Cancer cells escape immune recognition by exploiting the programmed cell-death protein 1 (PD-1)/programmed cell-death 1 ligand 1 (PD-L1) immune checkpoint axis. Immune checkpoint inhibitors that target PD-1/PD-L1 unleash the properties of effector T cells that are licensed to kill cancer cells. Immune checkpoint blockade has dramatically changed the treatment landscape of many cancers. Following the cancer paradigm, preliminary results of clinical trials in lymphoma have demonstrated that immune checkpoint inhibitors induce remarkable responses in specific subtypes, most notably classical Hodgkin lymphoma and primary mediastinal B-cell lymphoma, while in other subtypes, the results vary considerably, from promising to disappointing. Lymphomas that respond to immune checkpoint inhibitors tend to exhibit tumor cells that reside in a T-cell-rich immune microenvironment and display constitutive transcriptional upregulation of genes that facilitate innate immune resistance, such as structural variations of the PD-L1 locus, collectively referred to as T-cell-inflamed lymphomas, while those lacking such characteristics are referred to as noninflamed lymphomas. This distinction is not necessarily a sine qua non of response to immune checkpoint inhibitors, but rather a framework to move the field forward with a more rational approach. In this article, we provide insights on our current understanding of the biological mechanisms of immune checkpoint evasion in specific subtypes of B-cell and T-cell non-Hodgkin lymphomas and summarize the clinical experience of using inhibitors that target immune checkpoints in these subtypes. We also discuss the phenomenon of hyperprogression in T-cell lymphomas, related to the use of such inhibitors when T cells themselves are the target cells, and consider future approaches to refine clinical trials with immune checkpoint inhibitors in non-Hodgkin lymphomas.