Systematic literature review of the global burden of illness of mantle cell lymphoma

Optimizing Zanubrutinib Dosing in Patients: A PBPK-BO Model Approach to Drug-Drug Interactions and Patients with Hepatic Impairment

This study aimed to develop a physiologically based pharmacokinetic and Bruton's tyrosine kinase (BTK) occupancy (PBPK-BO) model to evaluate the pharmacokinetics (PK) and BTK occupancy (BO) of zanubrutinib (ZAN), particularly in relation to drug-drug interactions (DDIs) involving cytochrome P450 3A4 (CYP3A4) modulators and for patients with hepatic impairment. Population PBPK-BO and DDI models for ZAN were constructed using physicochemical properties, pharmacokinetic data, BTK occupancy levels, and physiological parameters. The PBPK-BO model was validated against clinically measured PK, DDI, and BO data, demonstrating accurate predictions of ZAN's plasma concentration and the time-course profiles of BO. The predicted ratios of AUC and Cmax in patients consistently fell within the acceptable range of 1.5-fold. The predicted fold-change ratios in DDIs and in patients with hepatic impairment also are in good agreement with the observed data. These findings confirm the reliability of the PBPK-BO model for predicting PK and BO of ZAN. Based on the model with >95% BO as a clinical efficacy threshold, the recommended dosing of ZAN should be reduced to 40 mg once daily (OD) when used with strong CYP3A4 inhibitors such as itraconazole or clarithromycin. For moderate CYP3A4 inhibitors like fluconazole, dosing should be adjusted to either 160 mg OD or 80 mg twice daily (BID). Additionally, the model advises against concomitant administration of ZAN with strong CYP3A4 inducers such as rifampicin or moderate inducers like rifabutin. Furthermore, the PBPK-BO model suggests that dosing regimens should be reduced to 80 mg BID or 160 mg OD in patients with severe hepatic impairment. The PBPK-BO model provides a robust framework for clinical decision-making, aimed at optimizing treatment outcomes in patients receiving ZAN therapy.

Real-world assessment to estimate multiple attributes related to treatment cost driver for mantle cell lymphoma in Japan by econometric modeling

This study was conducted using a nationwide health care database of Japan between 1 April 2008 and 30 September 2022 to evaluate the economic burden on patients with mantle cell lymphoma (MCL). Structural equation modeling (SEM) is an advanced multivariate analysis framework used to assess the relationships between observed and latent variables within predefined causal models. In this study, SEM was employed to identify cost drivers and estimate variables related to MCL treatment cost. A total of 2,838 patients having at least one confirmed diagnosis of MCL participated in this study. As for the index regimen, a combination of bendamustine rituximab was the most frequently used (n = 328), followed by rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisolone-like regimen (n = 112), and others. The median of total health care cost (unadjusted and adjusted) were 32,228 USD and 31,918 USD, respectively. The mean (SD) of the frequency of bleeding treatment was 23 (35) per year, and that of outpatient visits was 19 (12) per year. SEM analysis revealed Bruton tyrosine kinase inhibitor-based treatment as a cost driver (β: 0.398 [0.340; 0.457], p < 0.001). Key health care resource utilization (HCRU) factors associated with an increased cost were the total length of hospitalization (β: 0.598 [0.551; 0.646], p < 0.001) and number of outpatient visits (β: 0.132 [0.083; 0.180], p < 0.001). This real-world study delivers insights for optimizing MCL care in Japan.

Real-World Evidence of Relapsed/Refractory Mantle Cell Lymphoma Patients and Treatments: A Systematic Review

Introduction

Mantle cell lymphoma (MCL) is an incurable disease with an aggressive clinical course, and most patients eventually relapse after chemotherapy. Targeted therapies developed for relapsed/refractory MCL have been approved based on clinical trial data. However, real-world setting data are scarce and scattered.

Areas Covered

This systematic review aimed to collect, synthesize, and describe the characteristics and treatment outcomes of patients with relapsed/refractory MCL after receiving a second or subsequent line of therapy in the real-world setting.

Expert Opinion

R/R MCL is clinically and biologically heterogeneous and still represents a therapeutic challenge, with high-risk and early relapsed patients remaining an unmet medical need. This systematic review is limited by the quality of the available data and the difficulty of comparing outcomes in R/R MCL due to the heterogeneity of the disease, but the results suggest that covalent BTKis should be positioned as second-line therapy, followed by CAR T-cells in BTK-i-relapsed patients. Chemo-free and combination therapies with established chemoimmunotherapy backbones in the relapsed and front-line settings have been recently developed, and front-line options are being improved to move targeted and cellular therapies to earlier lines, including front-line therapy, in elderly and younger fit patients. In the upcoming years, many new targeted agents will play an important role and will be incorporated to the routine practice as their sequence, and outcomes in unselected patients are determined.

Estimating the Associated Burden of Illness and Healthcare Utilization of Newly Diagnosed Patients Aged ≥65 with Mantle Cell Lymphoma (MCL) in Ontario, Canada

BACKGROUND

With the emergence of therapies for mantle cell lymphoma (MCL), understanding the treatment patterns and burden of illness among older patients with MCL in Canada is essential to inform decision making.

METHODS

A retrospective study using administrative data matched individuals aged ≥65 who were newly diagnosed with MCL between 1 January 2013 and 31 December 2016 with general population controls. Cases were followed for up to 3 years in order to assess healthcare resource utilization (HCRU), healthcare costs, time to next treatment or death (TTNTD), and overall survival (OS); all were stratified according to first-line treatment.

RESULTS

This study matched 159 MCL patients to 636 controls. Direct healthcare costs were highest among MCL patients in the first year following diagnosis (Y1: CAD 77,555 ± 40,789), decreased subsequently (Y2: CAD 40,093 ± 28,720; Y3: CAD 36,059 ± 36,303), and were consistently higher than the costs for controls. The 3-year OS after MCL diagnosis was 68.6%, with patients receiving bendamustine + rituximab (BR) experiencing a significantly higher OS compared to patients treated with other regimens (72.4% vs. 55.6%, p = 0.041). Approximately 40.9% of MCL patients initiated a second-line therapy or died within 3 years.

CONCLUSION

Newly diagnosed MCL presents a substantial burden to the healthcare system, with almost half of all patients progressing to a second-line therapy or death within 3 years.

PAK4 and NAMPT as Novel Therapeutic Targets in Diffuse Large B-Cell Lymphoma, Follicular Lymphoma, and Mantle Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL), grade 3b follicular lymphoma (FL), and mantle cell lymphoma (MCL) are aggressive non-Hodgkin's lymphomas (NHL). Cure rates are suboptimal and novel treatment strategies are needed to improve outcomes. Here, we show that p21-activated kinase 4 (PAK4) and nicotinamide phosphoribosyl transferase (NAMPT) is critical for lymphoma subsistence. Dual targeting of PAK4-NAMPT by the Phase I small molecule KPT-9274 suppressed cell proliferation in DLBCL, FL, and MCL. Growth inhibition was concurrent with apoptosis induction alongside activation of pro-apoptotic proteins and reduced pro-survival markers. We observed NAD suppression, ATP reduction, and consequent cellular metabolic collapse in lymphoma cells due to KPT-9274 treatment. KPT-9274 in combination with standard-of-care chemotherapeutics led to superior inhibition of cell proliferation. In vivo, KPT-9274 could markedly suppress the growth of WSU-DLCL2 (DLBCL), Z-138, and JeKo-1 (MCL) sub-cutaneous xenografts, and a remarkable increase in host life span was shown, with a 50% cure of a systemic WSU-FSCCL (FL) model. Residual tumor analysis confirmed a reduction in total and phosphorylated PAK4 and activation of the pro-apoptotic cascade. This study, using various preclinical experimental models, demonstrates the therapeutic potential of targeting PAK4-NAMPT in DLBCL, FL, and MCL. The orally bioavailable, safe, and efficacious PAK4-NAMPT dual inhibitor KPT-9274 warrants further clinical investigation.

Blastoid Mantle Cell Lymphoma

Blastoid and pleomorphic mantle cell lymphoma (MCL) are among the worst prognostic, aggressive histology, high-risk variants of MCL, and, in this article, they are presented as blastoid MCL. Blastoid MCL have not been systematically studied, probably due to their rarity. De novo blastoid MCLs have superior outcomes compared with transformed MCL. Compared with classic MCL, extranodal involvement (mainly skin, central nervous system), frequent relapses, and inferior responses to conventional chemoimmunotherapy, BTK inhibitors and venetoclax are frequent in blastoid MCL. KTE-X19 induces excellent response in blastoid MCL. Combinations with novel agents are actively investigated. This article presents a comprehensive review on blastoid MCL in 2020.