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Costa RDO, Pereira J, Lage LADPC, Baiocchi OCG. Extranodal NK-/T-cell lymphoma, nasal type: what advances have been made in the last decade? Front Oncol 2023; 13:1175545. [PMID: 37529691 PMCID: PMC10388588 DOI: 10.3389/fonc.2023.1175545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Extranodal NK-/T-cell lymphoma (ENKTCL) is a rare and highly aggressive malignancy with significant racial and geographic variations worldwide. In addition to the formerly "nasal-type" initial description, these lymphomas are predominantly extranodal in origin and typically cause vascular damage and tissue destruction, and although not fully understood, Epstein-Barr virus (EBV) has an important role in its pathogenesis. Initial assessment must include a hematopathology review of representative and viable tumor areas without necrosis for adequate immunohistochemistry studies, including EBV-encoded small RNA (EBER) in situ hybridization (ISH). Positron emission tomography with 18-fluorodeoxyglucose (18F-FDG-PET/CT) for accurate staging is essential, and most patients will have localized disease (IE/IIE) at diagnosis. Apart from other T-cell malignancies, the best treatment even for localized cases is combined modality therapy (chemotherapy plus radiotherapy) with non-anthracycline-based regimens. For advanced-stage disease, l-asparaginase-containing regimens have shown improved survival, but relapsed and refractory cases have very poor outcomes. Nowadays, even with a better understanding of pathogenic pathways, up-front therapy is completely based on chemotherapy and radiotherapy, and treatment-related mortality is not low. Future strategies targeting signaling pathways and immunotherapy are evolving, but we need to better identify those patients with dismal outcomes in a pre-emptive way. Given the rarity of the disease, international collaborations are urgently needed, and clinical trials are the way to change the future.
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Affiliation(s)
- Renata de Oliveira Costa
- Department of Hematology, Faculdade de Ciências Médicas de Santos (FCMS), Centro Universitário Lusíadas (Unilus), Santos, São Paulo, Brazil
- Hospital Alemao Osvaldo Cruz (HAOC), São Paulo, Brazil
| | - Juliana Pereira
- Hospital Alemao Osvaldo Cruz (HAOC), São Paulo, Brazil
- Department of Hematology, Hemotherapy and Cell Therapy, Faculdade de Medicina da Universidade de Sao Paulo (FM-USP), São Paulo, Brazil
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of Sao Paulo (USP), São Paulo, Brazil
| | - Luís Alberto de Pádua Covas Lage
- Department of Hematology, Hemotherapy and Cell Therapy, Faculdade de Medicina da Universidade de Sao Paulo (FM-USP), São Paulo, Brazil
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), University of Sao Paulo (USP), São Paulo, Brazil
| | - Otávio César Guimarães Baiocchi
- Hospital Alemao Osvaldo Cruz (HAOC), São Paulo, Brazil
- Department of Hematology, Universidade Federal de Sao Paulo (Unifesp), São Paulo, Brazil
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2
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Lv K, Yin T, Yu M, Chen Z, Zhou Y, Li F. Treatment Advances in EBV Related Lymphoproliferative Diseases. Front Oncol 2022; 12:838817. [PMID: 35515118 PMCID: PMC9063483 DOI: 10.3389/fonc.2022.838817] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/11/2022] [Indexed: 12/24/2022] Open
Abstract
Epstein Barr virus (EBV) can affect 90% of the human population. It can invade B lymphocytes, T lymphocytes and natural killer cells of the host and remain in the host for life. The long latency and reactivation of EBV can cause malignant transformation, leading to various lymphoproliferative diseases (LPDs), including EBV-related B-cell lymphoproliferative diseases (EBV-B-LPDs) (for example, Burkitt lymphoma (BL), classic Hodgkin's lymphoma (cHL), and posttransplantation and HIV-related lymphoproliferative diseases) and EBV-related T-cell lymphoproliferative diseases (EBV-T/NK-LPDs) (for example, extranodal nasal type natural killer/T-cell lymphoma (ENKTCL), aggressive NK cell leukaemia (ANKL), and peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). EBV-LPDs are heterogeneous with different clinical features and prognoses. The treatment of EBV-LPDs is usually similar to that of EBV-negative lymphoma with the same histology and can include chemotherapy, radiotherapy, and hematopoietic stem cell transplant (HSCT). However, problems such as serious toxicity and drug resistance worsen the survival prognosis of patients. EBV expresses a variety of viral and lytic proteins that regulate cell cycle and death processes and promote the survival of tumour cells. Based on these characteristics, a series of treatment strategies for EBV in related malignant tumours have been developed, such as monoclonal antibodies, immune checkpoint inhibitors, cytotoxic T lymphocytes (CTLs) and epigenetic therapy. These new individualized therapies can produce highly specific killing effects on tumour cells, and nontumour cells can be protected from toxicity. This paper will focus on the latest progress in the treatment of EBV-LPDs based on pathological mechanisms.
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Affiliation(s)
- Kebing Lv
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ting Yin
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Min Yu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, China.,Clinical Research Center for Hematologic Disease of Jiangxi Province, Nanchang, China.,Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Zhiwei Chen
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, China.,Clinical Research Center for Hematologic Disease of Jiangxi Province, Nanchang, China.,Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Yulan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, China.,Clinical Research Center for Hematologic Disease of Jiangxi Province, Nanchang, China.,Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Institute of Hematology, Academy of Clinical Medicine of Jiangxi Province, Nanchang, China.,Clinical Research Center for Hematologic Disease of Jiangxi Province, Nanchang, China.,Institute of Lymphoma and Myeloma, Nanchang University, Nanchang, China
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3
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Rendón-Serna N, Correa-Londoño LA, Velásquez-Lopera MM, Bermudez-Muñoz M. Cell signaling in cutaneous T-cell lymphoma microenvironment: promising targets for molecular-specific treatment. Int J Dermatol 2021; 60:1462-1480. [PMID: 33835479 DOI: 10.1111/ijd.15451] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/31/2020] [Accepted: 01/12/2021] [Indexed: 01/01/2023]
Abstract
Cutaneous T-cell lymphomas (CTCL) result from the infiltration and proliferation of a population of T cells in the skin, inducing changes in the activity of both T cells and surrounding skin cells. In the CTCL microenvironment, cell interactions mediated by cell signaling pathways are altered. Defining changes in cell signaling enables to understand T-cell deregulations in the CTCL microenvironment and thus the progression of the disease. Moreover, characterizing signaling networks activated in CTCL stages can lead to consider new molecular biomarkers and therapeutic targets. Focusing on mycosis fungoides (MF), the most frequent variant of CTCL, and Sézary syndrome (SS), its leukemic variant, this review highlights recent molecular and genetic findings revealing modifications of key signaling pathways involved in (1) cell proliferation, cell growth, and cell survival such as MAP kinases and PI3K/Akt; (2) immune responses derived from TCR, TLR, JAK/STAT, and NF-kB; and (3) changes in tissue conditions such as extracellular matrix remodeling, hypoxia, and angiogenesis. Alterations in these signaling networks promote malignant T-cell proliferation and survival, T-cell migration, inflammation, and suppression of immune regulation of malignant T cells, making a skin microenvironment that allows disease progression. Targeting key proteins of these signaling pathways, using molecules already available and used in research, in clinical trials, and with other disease indications, can open the way to different therapeutic options in CTCL treatment.
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Affiliation(s)
- Natalia Rendón-Serna
- Instituto de Biología, Universidad de Antioquia, Medellin, Colombia.,Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Luis A Correa-Londoño
- Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Margarita M Velásquez-Lopera
- Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
| | - Maria Bermudez-Muñoz
- Instituto de Biología, Universidad de Antioquia, Medellin, Colombia.,Centro de Investigaciones Dermatológicas CIDERM, Facultad de Medicina, Universidad De Antioquia, Medellin, Colombia
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4
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Abstract
Extranodal natural killer (NK)/T-cell lymphoma, nasal type, is a rare peripheral T-cell lymphoma associated with Epstein-Barr virus. It most often presents as limited-stage disease in patients of East Asian descent with a palatal deformity caused by erosion of the tumor through the hard palate. Limited-stage disease is often curable with the use of l-asparaginase-based chemotherapy and high-dose radiation therapy. Obtaining an accurate diagnosis is essential, because treatment with standard lymphoma regimens and omission of radiation severely compromise the likelihood of long-term survival. Conversely, patients with advanced disease have a poor prognosis and are recommended for asparaginase-based chemotherapy followed by consolidation with autologous transplantation as a potentially curative approach. Progress often has been hampered by the rarity of this disease. However, discovery of common genetic alterations in pathways that promote growth and inhibit apoptosis, and actionable markers such as CD30 (among others), have begun to broaden the availability of novel drugs (eg, targeted therapies). There is also cautious optimism about immunotherapies, such as checkpoint blockade and novel cellular therapies that target Epstein-Barr virus. Advances in treatment and understanding of the genetic landscape of this disease offer hope for improved treatment outcomes.
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Affiliation(s)
- Pamela B Allen
- Winship Cancer Institute of Emory University, Atlanta, GA
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MELK mediates the stability of EZH2 through site-specific phosphorylation in extranodal natural killer/T-cell lymphoma. Blood 2020; 134:2046-2058. [PMID: 31434700 DOI: 10.1182/blood.2019000381] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/09/2019] [Indexed: 02/07/2023] Open
Abstract
Oncogenic EZH2 is overexpressed and extensively involved in the pathophysiology of different cancers including extranodal natural killer/T-cell lymphoma (NKTL). However, the mechanisms regarding EZH2 upregulation is poorly understood, and it still remains untargetable in NKTL. In this study, we examine EZH2 protein turnover in NKTL and identify MELK kinase as a regulator of EZH2 ubiquitination and turnover. Using quantitative mass spectrometry analysis, we observed a MELK-mediated increase of EZH2 S220 phosphorylation along with a concomitant loss of EZH2 K222 ubiquitination, suggesting a phosphorylation-dependent regulation of EZH2 ubiquitination. MELK inhibition through both chemical and genetic means led to ubiquitination and destabilization of EZH2 protein. Importantly, we determine that MELK is upregulated in NKTL, and its expression correlates with EZH2 protein expression as determined by tissue microarray derived from NKTL patients. FOXM1, which connected MELK to EZH2 signaling in glioma, was not involved in mediating EZH2 ubiquitination. Furthermore, we identify USP36 as the deubiquitinating enzyme that deubiquitinates EZH2 at K222. These findings uncover an important role of MELK and USP36 in mediating EZH2 stability in NKTL. Moreover, MELK overexpression led to decreased sensitivity to bortezomib treatment in NKTL based on deprivation of EZH2 ubiquitination. Therefore, modulation of EZH2 ubiquitination status by targeting MELK may be a new therapeutic strategy for NKTL patients with poor bortezomib response.
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6
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Denker S, Bittner A, Na IK, Kase J, Frick M, Anagnostopoulos I, Hummel M, Schmitt CA. A Phase I/II first-line study of R-CHOP plus B-cell receptor/NF-κB-double-targeting to molecularly assess therapy response. Int J Hematol Oncol 2019; 8:IJH20. [PMID: 31903182 PMCID: PMC6939221 DOI: 10.2217/ijh-2019-0010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The ImbruVeRCHOP trial is an investigator-initiated, multicenter, single-arm, open label Phase I/II study for patients 61–80 years of age with newly diagnosed CD20+ diffuse large B-cell lymphoma and a higher risk profile (International Prognostic Index ≥2). Patients receive standard chemotherapy (CHOP) plus immunotherapy (Rituximab), a biological agent (the proteasome inhibitor Bortezomib) and a signaling inhibitor (the Bruton's Tyrosine Kinase-targeting therapeutic Ibrutinib). Using an all-comers approach, but subjecting patients to another lymphoma biopsy acutely under first-cycle immune-chemo drug exposure, ImbruVeRCHOP seeks to identify an unbiased molecular responder signature that marks diffuse large B-cell lymphoma patients at risk and likely to benefit from this regimen as a double, proximal and distal B-cell receptor/NF-κB-co-targeting extension of the current R-CHOP standard of care. EudraCT-Number: 2015-003429-32; ClinicalTrials.gov identifier: NCT03129828. The study investigates a new therapeutic concept for elderly patients newly diagnosed with a particularly aggressive B-cell lymphoma type that combines classical chemotherapy and a therapeutic antibody (together reflecting the current standard) with two modern agents, directed against a critical signaling cascade in this cancer type. Beyond feasibility and efficacy, it is particularly important in this study to collect tumor samples not only prior to but also immediately during first drug exposure. Molecular profiling of the tumor co-interpreted with patient outcome is expected to predict which patients are likely to benefit from such an extension of the standard regimen.
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Affiliation(s)
- Sophy Denker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany
| | - Aitomi Bittner
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany
| | - Il-Kang Na
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany.,Experimental & Clinical Research Centre, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
| | - Julia Kase
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany
| | - Mareike Frick
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany
| | | | - Michael Hummel
- Institute for Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,German Cancer Consortium (DKTK) & German Cancer Research Centre (DKFZ), Heidelberg, Germany
| | - Clemens A Schmitt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, & Berlin Institute of Health; Medical Department of Hematology, Oncology & Tumor Immunology, Virchow Campus & Molekulares Krebsforschungszentrum, Berlin, Germany.,German Cancer Consortium (DKTK) & German Cancer Research Centre (DKFZ), Heidelberg, Germany.,Kepler Universitätsklinikum, Hematology & Oncology, Johannes Kepler University, Linz, Austria.,Max-Delbrück-Centre for Molecular Medicine in the Helmholtz Association, Berlin, Germany
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7
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Advances in the treatment of extranodal NK/T-cell lymphoma, nasal type. Blood 2018; 131:2528-2540. [PMID: 29602763 DOI: 10.1182/blood-2017-12-791418] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/29/2018] [Indexed: 12/18/2022] Open
Abstract
Extranodal natural killer/T-cell lymphoma, nasal type (ENKL) is a subtype of mature T- and natural killer cell lymphomas characterized by its association with Epstein-Barr virus and extranodal involvement. Although there is geographic variance in the frequency of ENKL, its clinical features are similar between Western countries and endemic areas, such as East Asia. Anthracycline-containing chemotherapy is not recommended to treat ENKL. No standard treatment has been established based on the results of randomized controlled trials. In patients with localized disease, radiotherapy is a core component of the recommended first-line therapy. Radiotherapy administered at 50 to 54 Gy, extended involved-site radiotherapy considering tumor invasiveness, and the use of intensity modulated radiation therapy or volumetric modulated arc therapy are associated with efficacy of radiotherapy. Although the use of concurrent chemoradiotherapy has been supported by the results of clinical trials, accumulating evidence supports the use of sequential chemoradiotherapy with non-anthracycline-containing regimens that include l-asparaginase and/or platinum anticancer agents. l-asparaginase-containing chemotherapy is a key component of first-line treatments for systemic ENKL. Hematopoietic stem cell transplantation is recommended as a front-line consolidation therapy for newly diagnosed advanced-stage ENKL. Newer agents including immune checkpoint inhibitors are being investigated for treating ENKL. In this modern ENKL treatment era, multidisciplinary efforts are needed to identify the best timing and sequencing of radiotherapy, l-asparaginase, platinum, newer agents, and hematopoietic stem cell transplantation.
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8
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Lymphoma epidemiology in Korea and the real clinical field including the Consortium for Improving Survival of Lymphoma (CISL) trial. Int J Hematol 2018; 107:395-404. [DOI: 10.1007/s12185-018-2403-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/12/2018] [Indexed: 12/18/2022]
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Chen C, He H. Treatment of relapsed extranodal natural killer/T-cell lymphoma with bortezomib plus fludarabine. Mol Clin Oncol 2017; 7:525-528. [PMID: 28855986 PMCID: PMC5574062 DOI: 10.3892/mco.2017.1364] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 04/13/2017] [Indexed: 11/06/2022] Open
Abstract
Extranodal NK/T cell lymphoma (ENKL) is a rare entity, associated with an aggressive clinical behavior and poor prognosis. The optimal treatment strategies, particularly for relapsed patients, have not been clearly determined. A 40-year-old female ENKL patient with orbital involvement as the first presentation was initially suspected to have an orbital pseudotumor. When the patient developed disease progression following treatment with methylprednisolone, biopsy of the orbital mass was performed. Histopathological examination of the biopsy specimen was consistent with the diagnosis of ENKL (Ann Arbor stage IE). The patient was then treated with radiotherapy followed by chemotherapy with dexamethasone, methotrexate, ifosfamide, L-asparaginase and etoposide (SMILE regimen). Despite an initial good response, the patient developed disease relapse and progression (stage IIIE). Subsequently, treatment was switched to a novel regimen comprising bortezomib and fludarabine as salvage therapy for two courses. A positron emission tomography scan revealed disappearance of the orbital tumor. The patient then received autologous hematopoietic stem cell transplantation. At the last follow-up (March 2017), the patient remained disease-free.
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Affiliation(s)
- Chen Chen
- Department of Hematology, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277101, P.R. China
| | - Hongmin He
- Department of Pathology, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277101, P.R. China
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Li X, Cui Y, Sun Z, Zhang L, Li L, Wang X, Wu J, Fu X, Ma W, Zhang X, Chang Y, Nan F, Li W, Su L, Wang J, Xue H, Zhang M. DDGP versus SMILE in Newly Diagnosed Advanced Natural Killer/T-Cell Lymphoma: A Randomized Controlled, Multicenter, Open-label Study in China. Clin Cancer Res 2016; 22:5223-5228. [PMID: 27060152 DOI: 10.1158/1078-0432.ccr-16-0153] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/30/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Xin Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Yingying Cui
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Zhenchang Sun
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Lei Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Ling Li
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Xinhua Wang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Jingjing Wu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Xiaorui Fu
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Wang Ma
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Xudong Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Yu Chang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Feifei Nan
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China
| | - Wencai Li
- Department of Pathology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Liping Su
- Department of Hematology, Shanxi Cancer Hospital, Taiyuan, Shanxi, China
| | - Jinghua Wang
- Department of Oncology, Nanjing General Hospital of Nanjing Military Command, Nanjing, Jiangsu, China
| | - Hongwei Xue
- Department of Oncology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Mingzhi Zhang
- Department of Oncology, The First Affiliated Hospital of Zhengzhou University; Lymphoma Diagnosis and Treatment Center of Henan Province, Zhengzhou, Henan, China.
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11
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Niu SQ, Yang Y, Li YY, Wen G, Wang L, Li ZM, Wang HY, Zhang LL, Xia YF, Zhang YJ. Primary site and regional lymph node involvement are independent prognostic factors for early-stage extranodal nasal-type natural killer/T cell lymphoma. CHINESE JOURNAL OF CANCER 2016; 35:34. [PMID: 27044275 PMCID: PMC4820898 DOI: 10.1186/s40880-016-0096-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/10/2015] [Indexed: 12/15/2022]
Abstract
Background Nasal-type extranodal natural killer/T-cell lymphoma (ENKTCL) originates primarily in the nasal cavity or extra-nasal sites within the upper aerodigestive tract. However, it is unclear whether the primary site can serve as an independent prognostic factor or whether the varying clinical outcomes observed with different primary sites can be attributed merely to their propensities of regional lymph node involvement. The aim of this study was to investigate the prognostic implications of the primary site and regional lymph node involvement in patients with early-stage nasal-type ENKTCL. Methods To develop a nomogram, we reviewed the clinical data of 215 consecutively diagnosed patients with early-stage nasal-type ENKTCL who were treated in Sun Yat-sen University Cancer Center with chemotherapy and radiotherapy between 2000 and 2011. The predictive accuracy and discriminative ability of the nomogram were determined using a concordance index (C-index) and calibration curve. Results The 5-year overall survival (OS) and progression-free survival (PFS) rates of patients with nasal ENKTCL were higher than those of patients with extra-nasal ENKTCL (OS: 68.2% vs. 46.0%, P = 0.030; PFS: 53.4% vs. 26.6%, P = 0.010). The 5-year OS and PFS rates of patients with Ann Arbor stage IE ENKTCL were higher than those of patients with Ann Arbor stage IIE ENKTCL (OS: 66.3% vs. 59.2%, P = 0.003; PFS: 51.4% vs. 40.3%, P = 0.009). Multivariate analysis showed that age >60 years, ECOG performance status score ≥2, elevated lactate dehydrogenase (LDH) level, extra-nasal primary site, and regional lymph node involvement were significantly associated with lower 5-year OS rate; age >60 years, elevated LDH level, extra-nasal primary site, and regional lymph node involvement were significantly associated with lower 5-year PFS rate. The nomogram included the primary site and regional lymph node involvement based on multivariate analysis. The calibration curve showed good agreement between the predicted and actual 5-year OS and PFS rates, and the C-indexes of the nomogram for the OS and PFS rates were 0.697 and 0.634, respectively. Conclusions The primary site and regional lymph node involvement are independent prognostic factors for early-stage ENKTCL treated with chemotherapy followed by definitive radiotherapy.
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Affiliation(s)
- Shao-Qing Niu
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510060, Guangdong, P.R. China
| | - Yong Yang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Cancer Hospital and Institute, Peking Union Medical College (PUMC) and Chinese Academy of Medical Sciences (CAMS), Beijing, 100021, P.R. China
| | - Yi-Yang Li
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Ge Wen
- Department of Nuclear Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, P.R. China
| | - Liang Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Zhi-Ming Li
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Han-Yu Wang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Lu-Lu Zhang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Yun-Fei Xia
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China
| | - Yu-Jing Zhang
- State Key Laboratory of Oncology in South China; Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China. .,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P.R. China.
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12
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DU HP, Yang QQ, Zhang YE. Bortezomib-based chemotherapy to treat refractory angioimmunoblastic T-cell lymphoma: A case report and review of the literature. Oncol Lett 2016; 11:2310-2314. [PMID: 26998168 DOI: 10.3892/ol.2016.4213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 01/12/2016] [Indexed: 11/06/2022] Open
Abstract
The peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of aggressive neoplasms that account for <15% of all non-Hodgkin's lymphoma cases in adults. Angioimmunoblastic T-cell lymphoma (AITL) is a specific subtype of PTCL. The tumor is frequently aggressive and there is currently no general consensus regarding an effective treatment strategy. The present study reports a case in which bortezomib combined with dexamethasone was used to treat refractory AITL. A 63-year-old woman was admitted to Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (Zhejiang, China) on August 17, 2013. The patient had been diagnosed with AITL for 4 months and had experienced a relapse of symptoms for the 4 days prior to admission. The patient demonstrated fever and dyspnea, accompanied by severe edema in the face and lower limbs, which later spread to the right upper limb. The patient was treated with bortezomib plus dexamethasone, which rapidly relieved the symptoms. The patient was subsequently administered an additional 2 cycles of bortezomib-based chemotherapy and survived for an additional 4 months, prior to succumbing to the disease. Only a small number of studies have reported the use of bortezomib in the treatment of T-cell lymphoma. The present study suggested that bortezomib-based treatment may be a reliable, safe and effective alternative for the treatment of relapsed/refractory PTCL. The efficacy of bortezomib as a treatment for PTCL requires additional evaluation in future studies.
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Affiliation(s)
- Hua-Ping DU
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Qian-Qian Yang
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
| | - Y E Zhang
- Department of Hematology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, P.R. China
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13
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Gemcitabine, navelbine, and doxorubicin as treatment for patients with refractory or relapsed T-cell lymphoma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:606752. [PMID: 25866797 PMCID: PMC4383323 DOI: 10.1155/2015/606752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 09/16/2014] [Indexed: 12/02/2022]
Abstract
T-cell lymphoma (TCL) is resistant to conventional chemotherapy. We retrospectively evaluated the therapeutic efficiency and toxicity of gemcitabine, navelbine, and doxorubicin (GND) in patients with refractory or relapsed TCL. From 2002 to 2012, 69 patients with refractory or relapsed TCL received GND treatment in our hospital. The treatment protocol comprised gemcitabine (800 mg/m2, group 1; 1000 mg/m2, group 2) on days 1 and 8, navelbine (25 mg/m2) on day 1, and doxorubicin (20 mg/m2) on day 1, repeated every 3 weeks. The overall response rate (ORR) was 65.2%. The median overall survival (OS) was 36 months. The 5-year estimated OS rate was 32.4%. The GND regimen was well tolerated. Subgroup analysis demonstrated that the ORR and CR for group 1 were similar. A longer median OS was observed for group 1. Significant difference in grades 3-4 toxicities was observed between groups 1 and 2 (P = 0.035). Our study indicated that gemcitabine (800 mg/m2) on days 1 and 8 every 21 days was favorable for pretreated TCL patients.
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14
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Wang YQ, Yang Y, Zhuo HY, Zou LQ, Jiang Y, Jiang M. Trial of LVDP regimen (L-asparaginase, etoposide, dexamethasone, and cisplatin, followed by radiotherapy) as first-line treatment for newly diagnosed, stage III/IV extranodal natural killer/T cell lymphoma. Med Oncol 2015; 32:435. [PMID: 25572807 DOI: 10.1007/s12032-014-0435-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/03/2014] [Indexed: 02/05/2023]
Abstract
Stage III/IV extranodal natural killer/T cell lymphoma (ENKL) has a poor response and poor survival. Given the sensitivity of ENKL to radiotherapy and the fact that there is no consensus on standard chemotherapy, we conducted a clinical trial of LVDP regimen, combining LVDP chemotherapy (containing etoposide, dexamethasone, L-asparaginase, and cisplatin), followed by radiotherapy as a consolidation therapy regimen, for newly diagnosed patients with stage III/IV ENKL to evaluate the efficacy and safety of this regimen. The primary endpoints were overall response rate (ORR) and survival [overall survival (OS) and progression-free survival (PFS)] at 1 or 2 years, while the secondary endpoints were toxicity and adverse effects. In total, 18 patients were enrolled in this trial from July 2010 to September 2013. The mean completed cycles of chemotherapy was 4.04 (range 1-8 cycles), and the ORR was 50 %. During a mean follow-up of 21.8 months (range 2-51 months), the 1-year OS and PFS rates were 72.2 and 50.0 %, respectively, the 2-year OS and PFS rates were 33.3 and 22.2 %, respectively, and the median OS and PFS were 23.0 and 10.5 months, respectively. Severe adverse effects during therapy included six cases of grade 3/4 bone marrow suppression and one case of grade 3 transaminase increase. Sex, eastern cancer oncology group, performance status, Korean Prognostic Index, International Prognostic index, and bone marrow infiltration may influence the prognosis of advanced-stage ENKL.
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Affiliation(s)
- Y Q Wang
- Center of Medical Oncology, West China Hospital, Sichuan University, Chengdu, People's Republic of China,
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15
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Castillo JJ, Reagan JL, Bishop KD, Apor E. Viral lymphomagenesis: from pathophysiology to the rationale for novel therapies. Br J Haematol 2014; 165:300-15. [DOI: 10.1111/bjh.12788] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jorge J. Castillo
- Division of Hematologic Malignancies; Dana-Farber Cancer Institute; Boston MA USA
| | - John L. Reagan
- Division of Hematology and Oncology; Rhode Island Hospital; Providence RI USA
| | - Kenneth D. Bishop
- Division of Hematology and Oncology; Rhode Island Hospital; Providence RI USA
| | - Emmanuel Apor
- Department of Medicine; Rhode Island Hospital; Providence RI USA
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16
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Gkotzamanidou M, Papadimitriou CA. Peripheral T-cell lymphoma: The role of hematopoietic stem cell transplantation. Crit Rev Oncol Hematol 2014; 89:248-61. [DOI: 10.1016/j.critrevonc.2013.08.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 08/18/2013] [Accepted: 08/30/2013] [Indexed: 12/22/2022] Open
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17
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Kansara R, Savage KJ. The problem with cyclophosphamide, doxorubicin, vincristine and prednisone for the treatment of peripheral T-cell lymphoma. Leuk Lymphoma 2014; 55:727-9. [PMID: 24295133 DOI: 10.3109/10428194.2013.858154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Roopesh Kansara
- Medical Oncology, British Columbia Cancer Agency , Vancouver, BC , Canada
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18
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Hamadani M, Abu Kar SM, Usmani SZ, Savani BN, Ayala E, Kharfan-Dabaja MA. Management of relapses after hematopoietic cell transplantation in T-cell non-Hodgkin lymphomas. Semin Hematol 2013; 51:73-86. [PMID: 24468319 DOI: 10.1053/j.seminhematol.2013.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
T-cell non-Hodgkin lymphomas (NHLs) are a heterogeneous group of malignancies that represent 10%-15% of all NHLs. The prognosis of relapsed T-cell NHL is poor, especially for those relapsing after an autologous (auto-) or allogeneic (allo-) hematopoietic cell transplantation (HCT). Disease relapse post auto-HCT is best managed on a clinical trial. In the absence of an investigational protocol, the choice of salvage therapies should take into account patient performance status, eligibility for an allo-HCT, and surface CD30 expression. CD30-directed therapies or aggressive salvage regimens can be used as a bridge to allo-HCT in medically fit patients. In the elderly or more infirm patients, single-agent therapies could be offered, aiming at palliation. Similarly, relapse after an allo-HCT is not uncommon and is a real challenge. Reduction in ongoing immune suppression or donor lymphocyte infusion are often considered in this setting to augment graft-versus-lymphoma (GVL) effects and can occasionally provide durable disease control. Clinical trials designed to investigate novel therapeutic agents with immunomodulatory properties to augment GVL effects (eg, histone deacetylase [HDAC] inhibitors, proteasome inhibitor, lenalidomide) or targeted therapies (eg, aurora A kinase inhibitors, anaplastic lymphoma kinase [ALK] inhibitors) are sorely needed to improve the dismal outcomes of T-cell NHL relapsing after an allo-HCT.
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Affiliation(s)
- Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI.
| | - Sarah M Abu Kar
- Division of Hematology-Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Saad Z Usmani
- Myeloma Institute for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Bipin N Savani
- Hematology and Stem Cell Transplantation Section, Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ernesto Ayala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida College of Medicine, Tampa, FL
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute and University of South Florida College of Medicine, Tampa, FL
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19
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Suh C, Kim WS, Kim JS, Park BB. Review of the clinical research conducted by the Consortium for Improving Survival of Lymphoma of the Korean Society of Hematology Lymphoma Working Party. Blood Res 2013; 48:171-7. [PMID: 24086936 PMCID: PMC3786276 DOI: 10.5045/br.2013.48.3.171] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/20/2013] [Accepted: 08/30/2013] [Indexed: 12/15/2022] Open
Abstract
The Consortium for Improving Survival of Lymphoma (CISL) in Korean Society of Hematology Lymphoma Working Party had first meeting in February, 2006 with 10 institutions and 12 members. Now CISL comprised of 64 centers. CISL has concentrated research activity on lymphomas which are relatively frequent in Korea and has tried to give favors for the Korean lymphoma patients. CISL has conducted more than 30 retrospective studies to evaluate Korean peculiar lymphoma subtypes. More than 30 prospective trials have been being performed for diffuse large B-cell lymphoma, marginal zone lymphoma, extra-nodal NK/T-cell lymphoma, and so on. The first prospective trial for advanced marginal zone lymphoma has led to use Rituximab containing chemotherapy with the re-imbursement of health insurance in Korea. The multi-center trials of the CISL with new therapeutic modalities will improve further the survival of lymphoma patients not only quantitatively but also qualitatively.
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Affiliation(s)
- Cheolwon Suh
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. ; CISL in KLWP, Korea
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20
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Jiang L, Li SJ, Jiang YM, Long JX, Wang RS, Su J, Zhang Y. The significance of combining radiotherapy with chemotherapy for early stage extranodal natural killer/T-cell lymphoma, nasal type: a systematic review and meta-analysis. Leuk Lymphoma 2013; 55:1038-48. [PMID: 23885795 DOI: 10.3109/10428194.2013.827789] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Radiotherapy is regarded as a primary treatment for early stage extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKTL). However, whether combined modality treatment (CMT) comprising radiotherapy and chemotherapy is necessary remains controversial. A systematic review and meta-analysis of studies was performed to evaluate the significance of combining radiotherapy with chemotherapy for early stage ENKTL. Comparison of CMT and radiotherapy alone (RT) showed no significant difference by the measurement of complete response (CR) (odds ratio [OR] 1.07; 95% confidence interval [CI] 0.73-1.58; p = 0.73), 5-year overall survival rate (OS) (HR 0.73; 95% CI 0.45-1.19; p = 0.21) and progression-free survival rate (PFS) (HR 0.76; 95% CI 0.50-1.17; p = 0.21). Additional chemotherapy did not decrease systemic failure (OR 1.52; 95% CI 0.97-2.40; p = 0.07), as well as locoregional failure (OR 0.94; 95% CI 0.52-1.73; p = 0.85). The results may support the assertion that the combination of radiotherapy with chemotherapy cannot improve treatment outcomes, but rather it increases adverse effects and financial costs. However, these results should be interpreted with caution.
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Affiliation(s)
- Li Jiang
- Department of Radiotherapy, The First Affiliated Hospital, Guangxi Medical University , Nanning , China
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21
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Kim TM, Kim S, Ahn YO, Lee SH, Kim DW, Heo DS. Anti-cancer activity of gemcitabine against natural killer cell leukemia/lymphoma. Leuk Lymphoma 2013; 55:940-3. [PMID: 23772641 DOI: 10.3109/10428194.2013.813505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Tae Min Kim
- Laboratory for Biologic Therapy of Cancer, Cancer Research Institute, Seoul National University College of Medicine , Seoul , Korea
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22
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Skarbnik AP, Burki M, Pro B. Peripheral T-cell lymphomas: a review of current approaches and hopes for the future. Front Oncol 2013; 3:138. [PMID: 23755375 PMCID: PMC3664833 DOI: 10.3389/fonc.2013.00138] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 05/13/2013] [Indexed: 12/19/2022] Open
Abstract
Peripheral T-cell lymphomas (PTCL) are a diverse group of lymphoproliferative disorders, which share a common denominator of overall poor prognosis, with few exceptions. In this article, the authors review current standard of care approaches for the treatment of PTCLs, the role of stem-cell/bone marrow transplantation, and current developments in novel targeted therapies.
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Affiliation(s)
- Alan P Skarbnik
- Medical Oncology, Fox Chase Cancer Center , Philadelphia, PA , USA
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23
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The role of high dose chemotherapy and autologous stem-cell transplantation in peripheral T-cell lymphoma: A review of the literature and new perspectives. Cancer Treat Rev 2013; 39:51-9. [DOI: 10.1016/j.ctrv.2012.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Accepted: 03/30/2012] [Indexed: 11/21/2022]
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24
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Ahn HK, Kim SJ, Hwang DW, Ko YH, Tang T, Lim ST, Kim WS. Gemcitabine alone and/or containing chemotherapy is efficient in refractory or relapsed NK/T-cell lymphoma. Invest New Drugs 2012; 31:469-72. [DOI: 10.1007/s10637-012-9889-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 10/08/2012] [Indexed: 11/29/2022]
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Hopfinger G, Griessl R, Sifft E, Taylor N, Kenner L, Greil R, Merkel O. Novel treatment avenues for peripheral T-cell lymphomas. Expert Opin Drug Discov 2012; 7:1149-63. [PMID: 22998641 DOI: 10.1517/17460441.2012.727392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Peripheral T-cell lymphomas (PTCLs) and natural killer (NK) or T-cell non-Hodgkin's lymphomas (NHLs) are a rare and heterogeneous class of diseases with generally poor prognosis. This work intends to provide a focused primer on clinical diagnosis, current treatment regimens, and novel therapeutic approaches. The recent WHO classification has defined 18 different subtypes of PTCL and NK T-cell lymphomas. Diagnosis is mainly based on histology, flow-cytometric analysis of surface molecules in the blood and bone marrow, cytogenetics/fluorescence in situ hybridization (FISH), and T-cell receptor (TCR) rearrangement. Staging as well as follow-up diagnostic procedures rely on imaging techniques such as computerized tomography (CT) and positron emission tomography (PET). Current chemotherapeutic regimens such as CHOP result in a 60 - 70% response rate; however, 5-year survival is only around 30%. Therefore, new treatment strategies are urgently needed. Currently, different drug classes are under scrutiny. AREAS COVERED The authors discuss substances that directly target the tumor cells. The article includes such substances as antimetabolites, antibodies, histone deacetylase inhibitors, tyrosine kinase inhibitors, and immunomodulatory substances such as lenalidomide. EXPERT OPINION In the future a close collaboration of geneticists, biochemists, and clinicians together with new technologies such as deep sequencing will allow the refinement of treatment strategies in many diseases including PTCLs and NHLs. This refinement will allow treatments to be prepared according to the need of the individual patient.
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Affiliation(s)
- Georg Hopfinger
- 3rd Medical Department with Hematology, Medical Oncology, Hemostaseology, Rheumatology and Infectiology of the Paracelsus Private Medical University, Laboratory for Immunological and Molecular Cancer Research, Müllner Hauptstrasse 48, 5020 Salzburg, Austria.
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Clinical implications of plasma Epstein-Barr virus DNA in early-stage extranodal nasal-type NK/T-cell lymphoma patients receiving primary radiotherapy. Blood 2012; 120:2003-10. [DOI: 10.1182/blood-2012-06-435024] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
The clinical value of plasma Epstein-Barr virus (EBV) DNA has not been evaluated in patients with early-stage extranodal nasal-type NK/T-cell lymphoma (NKTCL) receiving primary radiotherapy. Fifty-eight patients with stage I disease and 11 with stage II disease were recruited. High pretreatment EBV-DNA concentrations were associated with B-symptoms, elevated lactate dehydrogenase levels, and a high International Prognostic Index score. EBV-DNA levels significantly decreased after treatment. The 3-year overall survival (OS) rate was 82.6% for all patients. Stage I or II patients with a pretreatment EBV-DNA level of ≤ 500 copies/mL had 3-year OS and progression-free survival (PFS) rates of 97.1% and 79.0%, respectively, compared with 66.3% (P = .002) and 52.2% (P = .045) in patients with EBV-DNA levels of > 500 copies/mL. The 3-year OS and PFS rates for patients with undetectable EBV-DNA after treatment was significantly higher than patients with detectable EBV-DNA (OS, 92.0% vs 69.8%, P = .031; PFS, 77.5% vs 50.7%, P = .028). Similar results were observed in stage I patients. EBV-DNA levels correlate with tumor load and a poorer prognosis in early-stage NKTCL. The circulating EBV-DNA level could serve both as a valuable biomarker of tumor load for the accurate classification of early-stage NKTCL and as a prognostic factor.
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Kim SJ, Yoon DH, Kang HJ, Kim JS, Park SK, Kim HJ, Lee J, Ryoo BY, Ko YH, Huh J, Yang WI, Kim HK, Min SK, Lee SS, Do IG, Suh C, Kim WS. Bortezomib in combination with CHOP as first-line treatment for patients with stage III/IV peripheral T-cell lymphomas: a multicentre, single-arm, phase 2 trial. Eur J Cancer 2012; 48:3223-31. [PMID: 22770877 DOI: 10.1016/j.ejca.2012.06.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 06/04/2012] [Accepted: 06/06/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND We performed a phase II study to evaluate the efficacy of bortezomib in combination with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) as first-line treatment for patients with stage III/IV peripheral T-cell lymphomas (PTCLs) based on our phase I study results. METHODS Patients received bortezomib on days 1 and 8 at a dose of 1.6 mg/m(2) in addition to CHOP every 3 weeks for a total of six cycles. RESULTS Forty-six patients were enrolled: PTCL, not otherwise specified (PTCL-NOS, n=16), extranodal NK/T-cell lymphoma, nasal type (ENKTL, n=10), angioimmunoblastic T-cell lymphoma (AITL, n=8), ALK-negative anaplastic large-cell lymphoma (ALCL, n=6), cutaneous T-cell lymphoma (CTCL, n=5) and hepatosplenic T-cell lymphoma (n=1). Thirty patients achieved complete response (CR, 65%) and the overall response rate was 76% (35/46). Although the CR rate of ENKTL was only 30% (3/10), three subtypes of PTCLs (PTCL-NOS, AITL and ALCL) showed 87% of overall response rate (ORR) (26/30) and 73% of CR rate (22/30). However, the 3-year overall survival and progression-free survival were 47% and 35%, respectively due to frequent relapse after remission. Grade 3/4 leucopenia was the most frequent toxicity whereas neurotoxicity was tolerable: grade 1 or 2 of peripheral neuropathy. CONCLUSIONS The combined treatment of bortezomib and CHOP is an effective and feasible regimen for advanced-stage PTCLs other than ENKTL, with acceptable toxicity. However, future studies exploring new drug combinations are warranted to overcome relapse after remission.
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Affiliation(s)
- Seok Jin Kim
- Division of Hematology and Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Liu S, Yuan Z, Zhang C, Fu W, Hou J. Bortezomib-based treatment for relapsed and refractory angioimmunoblastic T-cell lymphoma: Case report and literature review. Oncol Lett 2012; 4:262-264. [PMID: 22844366 DOI: 10.3892/ol.2012.724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 05/14/2012] [Indexed: 11/05/2022] Open
Abstract
Angioimmunoblastic T-cell lymphoma (AITL) is a distinct peripheral T-cell lymphoma (PTCL) subtype, accounting for 15-20% of PTCL and 2% of all non-Hodgkin lymphoma (NHL), with a poor prognosis. In the present study, we describe a 76-year-old patient with AITL who failed to respond to conventional chemotherapy but responded to bortezomib-based treatment and demonstrated persistent clinical improvement at the 18-month follow-up. These data suggest that bortezomib-based treatment may be a reliable, safe and effective alternative for treating relapsed/refractory AITL.
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Affiliation(s)
- Shuyan Liu
- Department of Hematology, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai 200003, P.R. China
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29
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Jain S, Zain J, O’Connor O. Novel therapeutic agents for cutaneous T-Cell lymphoma. J Hematol Oncol 2012; 5:24. [PMID: 22594538 PMCID: PMC3418166 DOI: 10.1186/1756-8722-5-24] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 05/17/2012] [Indexed: 02/08/2023] Open
Abstract
Mycosis fungoides (MF) and Sezary Syndrome (SS) represent the most common subtypes of primary Cutaneous T-cell lymphoma (CTCL). Patients with advanced MF and SS have a poor prognosis leading to an interest in the development of new therapies with targeted mechanisms of action and acceptable safety profiles. In this review we focus on such novel strategies that have changed the treatment paradigm of this rare malignancy.
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Affiliation(s)
- Salvia Jain
- NYU Cancer Institute, Division of Hematology and Medical Oncology, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Jasmine Zain
- NYU Cancer Institute, Division of Hematology and Medical Oncology, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Owen O’Connor
- Center for Lymphoid Malignancies, The New York Presbyterian Hospital - Columbia University Medical Center, Columbia University Hospital - College of Physicians and Surgeons, 6 East 60th St., New York, N.Y, 10022, USA
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30
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Mato AR, Feldman T, Goy A. Proteasome inhibition and combination therapy for non-Hodgkin's lymphoma: from bench to bedside. Oncologist 2012; 17:694-707. [PMID: 22566373 PMCID: PMC3360909 DOI: 10.1634/theoncologist.2011-0341] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 03/16/2012] [Indexed: 11/17/2022] Open
Abstract
Although patients with B-cell non-Hodgkin's lymphoma (NHL) usually respond to initial conventional chemotherapy, they often relapse and mortality has continued to increase over the last three decades in spite of salvage therapy or high dose therapy and stem cell transplantation. Outcomes vary by subtype, but there continues to be a need for novel options that can help overcome chemotherapy resistance, offer new options as consolidation or maintenance therapy postinduction, and offer potentially less toxic combinations, especially in the elderly population. The bulk of these emerging novel agents for cancer treatment target important biological cellular processes. Bortezomib is the first in the class of proteasome inhibitors (PIs), which target the critical process of intracellular protein degradation or recycling and editing through the proteasome. Bortezomib is approved for the treatment of relapsed or refractory mantle cell lymphoma. The mechanisms of proteasome inhibition are very complex by nature (because they affect many pathways) and not fully understood. However, mechanisms of action shared by bortezomib and investigational PIs such as carfilzomib, marizomib, ONX-0912, and MLN9708 are distinct from those of other NHL treatments, making them attractive options for combination therapy. Preclinical evidence suggests that the PIs have additive and/or synergistic activity with a large number of agents both in vitro and in vivo, from cytotoxics to new biologicals, supporting a growing number of combination studies currently underway in NHL patients, as reviewed in this article. The results of these studies will help our understanding about how to best integrate proteasome inhibition in the management of NHL and continue to improve patient outcomes.
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Affiliation(s)
- Anthony R Mato
- Lymphoma Division, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, New Jersey, USA.
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Ahn HK, Suh C, Chuang SS, Suzumiya J, Ko YH, Kim SJ, Huh JR, Yoon DH, Oh SY, Kim JS, Lee SI, Park KW, Hsieh PP, Nakamura S, Yoshino T, Ito K, Nagatani T, Oshimi K, Suzuki R, Kim WS. Extranodal natural killer/T-cell lymphoma from skin or soft tissue: suggestion of treatment from multinational retrospective analysis. Ann Oncol 2012; 23:2703-2707. [PMID: 22547542 DOI: 10.1093/annonc/mds096] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical features and outcomes of extranodal natural killer/T-cell lymphoma (ENKL) arising from extranasal sites are not fully understood. The purpose of this study was to study the prognosis and treatment outcome of skin/soft tissue primary ENKL. PATIENTS AND METHODS This multicenter retrospective study included 48 patients with skin/soft tissue primary ENKL diagnosed from 1993 to 2010. RESULTS Patients with Ann Arbor stage I, T1-2N0M0 by International Society for Cutaneous Lymphomas-European Organization of Research and Treatment of Cancer TNM (tumour-node-metastasis) stage, International prognostic index score of 0-1, and a Korean prognostic index (KPI) score of 0-1 were associated with better survival. Four of five patients with T1-2N0M0 disease achieved complete response with radiation alone. In disseminated disease, only 6 of 13 patients responded to anthracycline-containing chemotherapy, and all the two patients receiving SMILE showed response. CONCLUSION In conclusion, we identified the prognostic value of KPI, and we suggest a treatment recommendation according to the TNM (tumour-node-metastasis) stage. Radiotherapy with/without chemotherapy seemed to be optimal in localized disease. In advanced stages, a more aggressive treatment regimen with newer agents should be sought.
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Affiliation(s)
- H K Ahn
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - C Suh
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - S S Chuang
- Department of Pathology, Chi-Mei Medical Center, Tainan and Taipei Medical University, Taipei, Taiwan
| | - J Suzumiya
- Department of Internal Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Y H Ko
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - S J Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - J R Huh
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul
| | - D H Yoon
- Department of Pathology, Chi-Mei Medical Center, Tainan and Taipei Medical University, Taipei, Taiwan
| | - S Y Oh
- Department of Internal Medicine, Dong-A University College of Medicine, Busan
| | - J S Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - S I Lee
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - K W Park
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - P P Hsieh
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, and Center for General Education, Yuh-Ing Junior College of Health Care and Management, Kaohsiung, Taiwan
| | - S Nakamura
- Department of Pathology, Nagoya University Graduate School of Medicine, Nagoya
| | - T Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
| | - K Ito
- Department of Dermatology, Niigata University Graduate School of Medicine, Niigata
| | - T Nagatani
- Department of Dermatology, Yokohama City University Medical Center, Yokohama
| | - K Oshimi
- Department of Hematology, Juntendo University, Tokyo
| | - R Suzuki
- Department of HSCT Data Management, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - W S Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul.
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El-Mallawany NK, Frazer JK, Van Vlierberghe P, Ferrando AA, Perkins S, Lim M, Chu Y, Cairo MS. Pediatric T- and NK-cell lymphomas: new biologic insights and treatment strategies. Blood Cancer J 2012; 2:e65. [PMID: 22829967 PMCID: PMC3346681 DOI: 10.1038/bcj.2012.8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 12/14/2011] [Accepted: 02/06/2012] [Indexed: 02/07/2023] Open
Abstract
T- and natural killer (NK)-cell lymphomas are challenging childhood neoplasms. These cancers have varying presentations, vast molecular heterogeneity, and several are quite unusual in the West, creating diagnostic challenges. Over 20 distinct T- and NK-cell neoplasms are recognized by the 2008 World Health Organization classification, demonstrating the diversity and potential complexity of these cases. In pediatric populations, selection of optimal therapy poses an additional quandary, as most of these malignancies have not been studied in large randomized clinical trials. Despite their rarity, exciting molecular discoveries are yielding insights into these clinicopathologic entities, improving the accuracy of our diagnoses of these cancers, and expanding our ability to effectively treat them, including the use of new targeted therapies. Here, we summarize this fascinating group of lymphomas, with particular attention to the three most common subtypes: T-lymphoblastic lymphoma, anaplastic large cell lymphoma, and peripheral T-cell lymphoma-not otherwise specified. We highlight recent findings regarding their molecular etiologies, new biologic markers, and cutting-edge therapeutic strategies applied to this intriguing class of neoplasms.
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Affiliation(s)
- N K El-Mallawany
- Department of Pediatrics, New York-Presbyterian, Morgan Stanley Children's Hospital, Columbia University, New York, NY, USA
| | - J K Frazer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - P Van Vlierberghe
- Institute of Cancer Genetics, Columbia University, New York, NY, USA
| | - A A Ferrando
- Institute of Cancer Genetics, Columbia University, New York, NY, USA
- Department of Medicine, New York-Presbyterian, Morgan Stanley Children's Hospital, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, New York-Presbyterian, Morgan Stanley Children's Hospital, Columbia University, New York, NY, USA
| | - S Perkins
- Department of Hematopathology, University of Utah, Salt Lake City, UT, USA
| | - M Lim
- Department of Hematopathology, University of Michigan, Ann Arbor, MI, USA
| | - Y Chu
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
| | - M S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, NY, USA
- Departments of Medicine, Pathology, Microbiology, Immunology, Cell Biology and Anatomy, New York Medical College, Valhalla, NY, USA
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Kim JE, Yoon DH, Jang G, Lee DH, Kim S, Park CS, Huh J, Kim WS, Park J, Lee JH, Lee SI, Suh C. A phase I/II study of bortezomib plus CHOP every 2 weeks (CHOP-14) in patients with advanced-stage diffuse large B-cell lymphomas. THE KOREAN JOURNAL OF HEMATOLOGY 2012; 47:53-9. [PMID: 22479278 PMCID: PMC3317471 DOI: 10.5045/kjh.2012.47.1.53] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 03/07/2012] [Accepted: 03/12/2012] [Indexed: 01/01/2023]
Abstract
Background Bortezomib targets molecular dysregulation of nuclear factor-κB activation and cell cycle control, which are characteristic features of diffuse large B-cell lymphoma (DLBCL). We evaluated the safety and efficacy of bortezomib treatment with dose-dense cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) every 2 weeks (CHOP-14). Methods Untreated DLBCL patients were enrolled. A phase I dose-escalation study with 1.0, 1.3, and 1.6 mg/m2 bortezomib administration on day 1 and 4 in addition to the CHOP-14 regimen was performed to determine the maximum tolerated dose (MTD) and the dose-limiting toxicity (DLT). Lenograstim 5 µg/kg/d was administered on day 4-13. The bortezomib dose from the phase I study was used in the phase II study. Results Nine and 37 patients were enrolled in the phase I and phase II studies, respectively. The analysis of the phase II results (40 patients) included data of the 3 patients in the last MTD dose cohort of the phase I trial. During the phase I trial, no DLT was observed at any bortezomib dose; therefore, the recommended dose was 1.6 mg/m2. In phase II, the overall response rate was 95% (complete response: 80%; partial response: 15%). Nine out of the 40 patients showed grade 3 sensory neuropathy, and 22 required at least 1 dose reduction. Three patients could not complete the intended 6 cycles of treatment because of severe neuropathy. Conclusion Bortezomib plus CHOP-14 was highly effective for the treatment of untreated DLBCL patients, but in many cases, dose or schedule modification was required to reduce neurotoxicity.
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Affiliation(s)
- Jeong Eun Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Clinical Trials and Treatment of ATL. LEUKEMIA RESEARCH AND TREATMENT 2012; 2012:101754. [PMID: 23259064 PMCID: PMC3505932 DOI: 10.1155/2012/101754] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 09/29/2011] [Indexed: 12/03/2022]
Abstract
ATL is a distinct peripheral T-lymphocytic malignancy associated with human T-cell lymphotropic virus type I (HTLV-1). The diversity in clinical features and prognosis of patients with this disease has led to its subtype-classification into four categories, acute, lymphoma, chronic, and smoldering types, defined by organ involvement, and LDH and calcium values. In case of acute, lymphoma, or unfavorable chronic subtypes (aggressive ATL), intensive chemotherapy like the LSG15 regimen (VCAP-AMP-VECP) is usually recommended if outside of clinical trials, based on the results of a phase 3 trial. In case of favorable chronic or smoldering ATL (indolent ATL), watchful waiting until disease progression has been recommended, although the long-term prognosis was inferior to those of, for instance, chronic lymphoid leukemia. Retrospective analysis suggested that the combination of interferon alpha and zidovudine was apparently promising for the treatment of ATL, especially for types with leukemic manifestation. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is also promising for the treatment of aggressive ATL possibly reflecting graft versus ATL effect. Several new agent trials for ATL are ongoing and in preparation, including a defucosylated humanized anti-CC chemokine receptor 4 monoclonal antibody, IL2-fused with diphtheria toxin, histone deacetylase inhibitors, a purine nucleoside phosphorylase inhibitor, a proteasome inhibitor, and lenalidomide.
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Abstract
AbstractPeripheral T-cell lymphomas (PTCLs) are a rare and heterogeneous group of disorders that, for the most part, are associated with a very poor prognosis. The standard therapy for PTCLs is CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or a comparable CHOP-like regimen that incorporates anthracyclines. With the exception of anaplastic lymphoma kinase–positive anaplastic large cell lymphoma (ALK+ ALCL), the cure rate for PTCLs with CHOP is low, and limited evidence suggests that anthracyclines do not improve the prognosis. However, there is no compelling evidence that any other regimen or approach is superior. It remains challenging to compare alternative therapies or treatment strategies with CHOP because the majority of data are retrospective and include diverse patient populations. Recently, prospective studies have been initiated exclusively for PTCL, and in some, select histologic subtypes are evaluated in an effort to remove heterogeneity. Encouragingly, there have been several new therapies emerging with activity in PTCLs and exciting novel combinations under consideration that will hopefully move the field forward and improve outcome in this challenging group of diseases.
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Roncolato F, Gazzola A, Zinzani PL, Pileri SA, Piccaluga PP. Targeted molecular therapy in peripheral T-cell lymphomas. Expert Rev Hematol 2011; 4:551-562. [PMID: 21939422 DOI: 10.1586/ehm.11.55] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Peripheral T-cell lymphomas (PTCLs) are rare neoplasms constituting a heterogeneous group of diseases. At present, available chemotherapy regimens that have improved outcomes in B-cell lymphomas appear to be less efficacious in the context of PTCLs and, thus, alternative strategies are warranted. In the last few years, based on the recent, deeper understanding of PTCL biology, several molecules and/or pathways have been proposed for targeted therapy in this setting, including surface antigens, tyrosine kinases, the NF-κB pathway, folate metabolism, histone modification and others. Of particular interest, histone deacetylase and proteasome inhibitors, as well as novel chemotherapeutic agents such as pralatrexate, have already demonstrated efficacy in PTCL therapy. In addition, a strong biological rationale and early clinical evidence supports the future study of tyrosine kinase inhibitors in this setting. In this article, the authors review the available literature on targeted therapy in PTCLs and also, based on their own experience, discuss potential opportunities in this intriguing area.
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Phillips AA, Owens C, Lee S, Bhagat G. An update on the management of peripheral T-cell lymphoma and emerging treatment options. J Blood Med 2011; 2:119-29. [PMID: 22287871 PMCID: PMC3262352 DOI: 10.2147/jbm.s8627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Indexed: 11/23/2022] Open
Abstract
Peripheral T-cell lymphomas (PTCLs) comprise a rare and heterogeneous subset of non-Hodgkin’s lymphomas (NHLs) that arise from post-thymic T-cells or natural killer (NK)-cells at nodal or extranodal sites. Worldwide, PTCLs represent approximately 12% of all NHLs and the 2008 World Health Organization (WHO) classification includes over 20 biologically and clinically distinct T/NK-cell neoplasms that differ significantly in presentation, pathology, and response to therapy. Because of the rarity and heterogeneity of these diseases, large clinical trials have not been conducted and optimal therapy is not well defined. Most subtypes are treated with similar combination chemotherapy regimens as used for aggressive B-cell NHL, but with poorer outcomes. New treatment combinations and novel agents are currently being explored for PTCLs and this review highlights a number of options that appear promising.
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Sehn LH, MacDonald D, Rubin S, Cantin G, Rubinger M, Lemieux B, Basi S, Imrie K, Gascoyne RD, Sussman J, Chen BE, Djurfeldt M, Shepherd L, Couban S, Crump M. Bortezomib Added to R-CVP Is Safe and Effective for Previously Untreated Advanced-Stage Follicular Lymphoma: A Phase II Study by the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 2011; 29:3396-401. [DOI: 10.1200/jco.2010.33.6594] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Bortezomib has demonstrated promising activity in patients with follicular lymphoma (FL). This is the first study to evaluate the safety and efficacy of bortezomib added to rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP) in previously untreated advanced-stage FL. Patients and Methods This is a phase II multicenter trial adding bortezomib (1.3 mg/m2 days 1 and 8) to standard-dose R-CVP (BR-CVP) for up to eight cycles in patients with newly diagnosed stage III/IV FL requiring therapy. Two co-primary end points, complete response rate (complete response [CR]/CR unconfirmed [CRu]) and incidence of grade 3 or 4 neurotoxicity, were assessed. Results Between December 2006 and March 2009, 94 patients were treated with BR-CVP. Median patient age was 57 years (range, 29 to 84 years), and the majority had a high (47%) or intermediate (43%) Follicular Lymphoma International Prognostic Index score. BR-CVP was extremely well tolerated, with 90% of patients completing the intended eight cycles. No patients developed grade 4 neurotoxicity, and only five of 94 patients (5%; 95% CI, 0.8% to 9.9%) developed grade 3 neurotoxicity, which was largely reversible. On the basis of an intention-to-treat analysis, 46 of 94 patients (49%; 95% CI, 38.8% to 59.0%) achieved a CR/CRu, and 32 of 94 patients (34%) achieved a partial response, for an overall response rate of 83% (95% CI, 75.4% to 90.6%). Conclusion The addition of bortezomib to standard-dose R-CVP for advanced-stage FL is feasible and well tolerated with minimal additional toxicity. The complete response rate in this high-risk population compares favorably to historical results of patients receiving R-CVP. Given these results, a phase III trial comparing BR-CVP with R-CVP is planned.
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Affiliation(s)
- Laurie H. Sehn
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - David MacDonald
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Sheldon Rubin
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Guy Cantin
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Morel Rubinger
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Bernard Lemieux
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Sanraj Basi
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Kevin Imrie
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Randy D. Gascoyne
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Jonathan Sussman
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Bingshu E. Chen
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Marina Djurfeldt
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Lois Shepherd
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Stephen Couban
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
| | - Michael Crump
- From the National Cancer Institute of Canada Clinical Trials Group, Kingston, Ontario, Canada
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Hu X, Xu J, Sun A, Shen Y, He G, Guo F. Successful T-cell acute lymphoblastic leukemia treatment with proteasome inhibitor bortezomib based on evaluation of nuclear factor-κB activity. Leuk Lymphoma 2011; 52:2393-5. [DOI: 10.3109/10428194.2011.593271] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Howman RA, Prince HM. New drug therapies in peripheral T-cell lymphoma. Expert Rev Anticancer Ther 2011; 11:457-72. [PMID: 21417858 DOI: 10.1586/era.11.4] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Peripheral T-cell lymphomas (PTCLs) are a heterogeneous collection of lymphomas that are associated with very poor prognosis. Conventional therapies, historically based on protocols for aggressive B-cell lymphomas, deliver less than adequate outcomes; the majority of patients experience early relapse after front-line treatment and current 5-year overall survival is only 10-30%. Clearly, new approaches are needed. In recent years there has been a plethora of novel agents showing activity in PTCL, often in patients with advanced relapsed or refractory disease. These agents include antifolate drugs (pralatrexate), histone deacetylase inhibitors (vorinostat, romidepsin, panobinostat and belinostat), nucleoside analogues (gemcitabine, forodesine and clofarabine), monoclonal antibodies (anti-CD52, anti-CD4 and anti-CD2), fusion toxins (denileukin diftitox), immunomodulatory agents (lenalidomide) and proteasome inhibitors (bortezomib). This is an exciting time in the treatment of PTCL, as our ever improving understanding of the distinguishing features, pathogenesis, molecular biology and progression of PTCL, and the knowledge of the mechanism and efficacy of novel therapies, may see a real improvement in outcomes for patients. The purpose of this article is to focus on these novel therapies and the results of recent clinical trials in PTCL.
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Affiliation(s)
- Rebecca A Howman
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
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Ishida F, Kwong YL. Diagnosis and management of natural killer-cell malignancies. Expert Rev Hematol 2011; 3:593-602. [PMID: 21083476 DOI: 10.1586/ehm.10.51] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Natural killer (NK)-cell malignancies are uncommon neoplasms, which have been referred to as polymorphic reticulosis or angiocentric T-cell lymphomas in the past. In the current WHO classification, they are categorized as extranodal NK/T-cell lymphoma, nasal type and aggressive NK-cell leukemia. NK-cell malignancies show a geographical predilection for Asian and South American populations and are rare in the west. Pathologically, NK-cell lymphomas show a polymorphic neoplastic infiltrate with angioinvasion and angiodestruction. The lymphoma cells are CD2(+), cytoplasmic CD3ε(+) and CD56(+), with germline T-cell receptor gene. There is an almost invariable clonal episomal infection with Epstein-Barr virus. Clinically, NK-cell lymphomas can be classified into nasal, non-nasal and aggressive lymphoma/leukemia subtypes. Most nasal NK-cell lymphomas present with stage I/II disease. The early use of radiotherapy, either alone or concomitantly/sequentially with chemotherapy, is the most important factor in achieving successful treatment. Many stage I/II patients receiving radiotherapy alone fail systemically, so the use of chemotherapy is also considered necessary. Chemotherapy is indicated for stage III/IV nasal NK-cell lymphoma, and the non-nasal and aggressive subtypes. Recent regimens that incorporate the use of L-asparaginase have resulted in substantial improvements in outcome in high-risk, refractory or relapsed patients. High-dose chemotherapy and hematopoietic stem-cell transplantation with autologous or allogeneic hematopoietic stem cells may be beneficial to selected patients. Prognostication of patients with clinical prognostic models and presentation circulating Epstein-Barr DNA load may be useful in the stratification of patients for various treatment modalities.
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Rigo M, Chentouf M, Pèlegrin A, Chardès T. CD4 ligation excludes the Carma1-Bcl10-MALT1 complex from GM1-positive membrane rafts in CD3/CD28 activated T cells. Cell Immunol 2011; 270:40-6. [PMID: 21489413 DOI: 10.1016/j.cellimm.2011.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 02/01/2011] [Accepted: 03/24/2011] [Indexed: 11/18/2022]
Abstract
The antibody 13B8.2, which is directed against the CDR3-like loop on the D1 domain of CD4, induces CD4/ZAP-70 reorganization and ceramide release in membrane rafts. Here, we investigated whether CD4/ZAP-70 compartmentalization could be mediated by an effect of 13B8.2 on the Carma1-Bcl10-MALT1 complex in membrane rafts. We report that treatment of CD3/CD28-activated Jurkat T cells with 13B8.2, but not rituximab, excluded Carma1-Bcl10-MALT1 proteins from GM1(+) membrane rafts and concomitantly decreased NF-κB activation. Fluorescence confocal imaging confirmed that Carma1-Bcl10 and Carma1-MALT1 co-patching, observed in GM1(+) membrane rafts following CD3/CD28 activation, were abrogated after a 24h-treatment with 13B8.2. The CD4/ZAP-70 compartmentalization in membrane rafts induced by 13B8.2 is thus related to Carma1-Bcl10-MALT1 raft exclusion.
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Affiliation(s)
- Maxime Rigo
- IRCM, Institut de Recherche en Cancérologie de Montpellier, Montpellier F-34298, France
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Iwata S, Yano S, Ito Y, Ushijima Y, Gotoh K, Kawada JI, Fujiwara S, Sugimoto K, Isobe Y, Nishiyama Y, Kimura H. Bortezomib induces apoptosis in T lymphoma cells and natural killer lymphoma cells independent of Epstein-Barr virus infection. Int J Cancer 2011; 129:2263-73. [PMID: 21170988 DOI: 10.1002/ijc.25873] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 11/30/2010] [Indexed: 12/11/2022]
Abstract
Epstein-Barr virus (EBV), which infects not only B cells, but also T cells and natural killer (NK) cells, is associated with multiple lymphoid malignancies. Recently, the proteasome inhibitor bortezomib was reported to induce apoptosis of EBV-transformed B cells. We evaluated the killing effect of this proteasome inhibitor on EBV-associated T lymphoma cells and NK lymphoma cells. First, we found that bortezomib treatment decreased the viability of multiple T and NK cell lines. No significant difference was observed between EBV-positive and EBV-negative cell lines. The decreased viability in response to bortezomib treatment was abrogated by a pan-caspase inhibitor. The induction of apoptosis was confirmed by flow cytometric assessment of annexin V staining. Additionally, cleavage of caspases and polyadenosine diphosphate-ribose polymerase, increased expression of phosphorylated IκB, and decreased expression of inhibitor of apoptotic proteins were detected by immunoblotting in bortezomib-treated cell lines. We found that bortezomib induced lytic infection in EBV-positive T cell lines, although the existence of EBV did not modulate the killing effect of bortezomib. Finally, we administered bortezomib to peripheral blood mononuclear cells from five patients with EBV-associated lymphoproliferative diseases. Bortezomib had a greater killing effect on EBV-infected cells. These results indicate that bortezomib killed T or NK lymphoma cells by inducing apoptosis, regardless of the presence or absence of EBV.
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Affiliation(s)
- Seiko Iwata
- Department of Virology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Rapid Remission in Peripheral T-Cell Lymphoma of the Nasal Type by the Bortezomib plus CHOP Therapy. Case Rep Med 2011; 2010:403237. [PMID: 21209804 PMCID: PMC3014791 DOI: 10.1155/2010/403237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 11/21/2010] [Accepted: 12/12/2010] [Indexed: 11/17/2022] Open
Abstract
Peripheral T-cell lymphoma (PTCL) is rare and difficult to treat for its high relapse rate. The authors report a case of PTCL of the skin, regarding which clinical and pathological features, treatment, and prognosis were discussed. A 66-year-old woman was admitted with complaints of enlarging erythematous noduloplaques on the right anterior tibial skin for one year and similar lesions on the left for 6 months. Surgical resection of right leg lesion and biopsy of enlarged inguinal lymph nodes histologically indicated a PTCL of the nasal type. The patient was treated by CHOP plus bortezomib, reached complete remission just after two courses of chemotherapy and then received another two as consolidation. The patient remained in remission for 11 months until local relapse. As for cutaneous lesions, detailed lymph node examination and prompt tissue biopsy are judicious choices prior to any medical management. The chemotherapy consisting of bortezomib and CHOP is safe and efficient in PTCL of the skin.
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Hwang YY, Liang RHS. An update in management of noncutaneous T-cell lymphomas. Adv Hematol 2010; 2010:424786. [PMID: 21188274 PMCID: PMC3003949 DOI: 10.1155/2010/424786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 10/28/2010] [Indexed: 12/30/2022] Open
Abstract
T-cell lymphoma is a heterogeneous group of diseases. Except for ALK positive anaplastic large cell lymphoma, T-cell lymphoma responds to conventional chemotherapy unfavourably, and most patients carry poor prognosis. In recent years, efforts have been made to improve the outcome of T-cell lymphoma patients. Novel agents, high-dose therapy, and allogeneic stem cell transplantation are studied, and various results are reported in literature. This paper looks into the prognostication and treatment approach of different entities of noncutaneous T-cell lymphoma and would focus on the latest updates in its management.
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Affiliation(s)
- Y. Y. Hwang
- Division of Haematology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - R. H. S. Liang
- Division of Haematology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
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Dunleavy K, Piekarz RL, Zain J, Janik JE, Wilson WH, O'Connor OA, Bates SE. New strategies in peripheral T-cell lymphoma: understanding tumor biology and developing novel therapies. Clin Cancer Res 2010; 16:5608-17. [PMID: 21138864 PMCID: PMC3058794 DOI: 10.1158/1078-0432.ccr-09-1995] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Peripheral T-cell lymphomas (PTCL) constitute a group of heterogeneous diseases that are uncommon, representing, in Western countries, only approximately 10% of all non-Hodgkin lymphomas. They are typically associated with a poor prognosis compared with their B-cell counterparts and are much less well understood with respect to tumor biology, owing to their rarity and biologic heterogeneity, and to the fact that characteristic cytogenetic abnormalities are few compared with B-cell lymphomas. Although the outcome for patients with anaplastic large cell lymphoma (ALCL), particularly anaplastic lymphoma kinase (ALK)-positive ALCL, is good, other types of PTCLs are associated with a poor prognosis, even with aggressive anthracycline-based chemotherapy. In this respect, there is a need for new approaches in these diseases, and this review focuses on and explores recent experience with novel therapies in PTCL.
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Affiliation(s)
- Kieron Dunleavy
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland 20892–1868, USA.
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Furman RR, Martin P, Ruan J, Cheung YKK, Vose JM, LaCasce AS, Elstrom R, Coleman M, Leonard JP. Phase 1 trial of bortezomib plus R-CHOP in previously untreated patients with aggressive non-Hodgkin lymphoma. Cancer 2010; 116:5432-9. [DOI: 10.1002/cncr.25509] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 05/23/2010] [Accepted: 06/07/2009] [Indexed: 12/20/2022]
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Abstract
Though peripheral T-cell lymphoma (PTCL) is an area of significant unmet therapeutic need, a number of new treatment options are available for patients, especially those with relapsed or refractory disease. A plethora of drugs are now in development for PTCL, but drugs that truly target novel disease biology are noticeably absent. Combinations of T-cell centric agents could produce novel platforms of therapy to replace the relatively ineffective CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone)-based regimens. Among agents with T-cell activity are the folate analog pralatrexate, histone deacetylase inhibitors (HDACi) like romidepsin, the proteasome inhibitor bortezomib, the immunomodulatory agent lenalidomide, the purine nucleoside phosphorylase (PNP) inhibitor forodesine, the nucleoside analog gemcitabine, and BH3-only mimetics like ABT-263 and ABT-737.
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Affiliation(s)
- Owen A O'Connor
- New York University Cancer Institute, NYU Langone Medical Center, New York, NY, USA. O'
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Shi WY, Wang L, Xiao D, Yao Y, Yang F, Jiang XX, Leboeuf C, Janin A, Chen SJ, Zhao WL. Proteasome inhibitor bortezomib targeted tumor-endothelial cell interaction in T-cell leukemia/lymphoma. Ann Hematol 2010; 90:53-8. [PMID: 20617436 DOI: 10.1007/s00277-010-1022-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2010] [Accepted: 06/21/2010] [Indexed: 11/28/2022]
Abstract
Endothelial cells have special relevance in tumor progression. Here, we investigated the effect of the proteasome inhibitor bortezomib on tumor-endothelial cell interaction in T-cell leukemia/lymphoma. In vitro, T-leukemia/lymphoma cell lines and primary T-leukemia/lymphoma cells were cultured with endothelial cells, either together or separately in Millicell Hanging Cell Culture system, the latter permits mutual cell exchange. At clinically achievable concentrations, in addition to a direct cytotoxicity on T-leukemia/lymphoma cells, bortezomib inhibited tumor cell adhesion to endothelial cells and endothelial cell migration toward tumor cells. In vivo, a murine tumor xenograft model was achieved by subcutaneous injection of Jurkat cells. Bortezomib also triggered an inhibition on tumor-endothelial cell contact and subsequent tumor cell infiltration. Cell adhesion molecule intracellular cell adhesion molecule-1 expression was significantly downregulated both on the tumor cells and on the endothelial cells. Taken together, bortezomib could not only act on tumor cells themselves but also abrogate tumor cell interaction with endothelial cells. This delineates another therapeutic mechanism of bortezomib in T-cell malignancies.
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Affiliation(s)
- Wen-Yu Shi
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Shanghai Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Rui Jin Er Road, Shanghai 200025, China
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Targeted treatment and new agents in peripheral T-cell lymphoma. Int J Hematol 2010; 92:33-44. [DOI: 10.1007/s12185-010-0614-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 05/19/2010] [Accepted: 05/24/2010] [Indexed: 10/19/2022]
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