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Kapoor P, Paludo J, Abeykoon JP. Frontline Management of Waldenström Macroglobulinemia with Chemoimmunotherapy. Hematol Oncol Clin North Am 2023:S0889-8588(23)00037-0. [PMID: 37246086 DOI: 10.1016/j.hoc.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Despite the introduction of effective novel agents, chemoimmunotherapy (CIT), with its widespread use, retains relevance and is one of the 2 vastly disparate strategies to treat Waldenström macroglobulinemia (WM), the alternative being the Bruton tyrosine kinase inhibitor (BTKi)-based approach. Considerable evidence over the past decades supports the integration of the monoclonal anti-CD20 antibody, rituximab, to the CIT backbone in WM, a CD20+ malignancy. Besides substantial efficacy, the finite duration of the treatment, coupled with lower rates of cumulative and long-term, clinically significant adverse effects and greater affordability, make CIT appealing, notwithstanding the lack of quality-of-life data with such an approach in WM. A phase 3 randomized controlled trial reported substantially higher efficacy and a more favorable safety profile of the bendamustine-rituximab (BR) doublet compared with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) among patients with WM. Subsequent studies reaffirmed its high efficacy and tolerability, making BR the mainstay of managing treatment-naïve patients with WM. High-quality evidence supporting the use of BR over Dexamethasone, Rituximab, and Cyclophosphamide (DRC), another commonly used regimen, is lacking, as is its comparison with the continuous BTKi-based approach. However, DRC appeared less potent than BR in cross-trial comparisons and retrospective series involving treatment-naïve patients with WM. Additionally, a recent retrospective, international study demonstrated comparable outcomes with fixed-duration BR and continuous ibrutinib monotherapy among previously untreated, age-matched patients exhibiting MYD88L265P mutation. However, unlike ibrutinib, BR appears effective irrespective of the MYD88 mutation status. CIT, preferably BR, is well suited to serve as the control arm (comparator) regimen against which novel targeted agents may be evaluated as frontline therapies for WM in high-quality trials. Purine analog-based CIT has been extensively evaluated in WM, although its use has waned, even in the multiply relapsed patient population, as effective and safer alternatives emerge.
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Affiliation(s)
- Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Jonas Paludo
- Division of Hematology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jithma P Abeykoon
- Division of Hematology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Tam CS, Kapoor P, Castillo JJ, Buske C, Ansell SM, Branagan AR, Kimby E, Li Y, Palomba ML, Qiu L, Shadman M, Abeykoon JP, Sarosiek S, Vos J, Yi S, Stephens D, Roos-Weil D, Roccaro AM, Morel P, Munshi NC, Anderson KC, San-Miguel J, Garcia-Sanz R, Dimopoulos MA, Treon SP, Kersten MJ. Report of consensus panel 7 from the 11th international workshop on Waldenström macroglobulinemia on priorities for novel clinical trials. Semin Hematol 2023; 60:118-124. [PMID: 37099031 DOI: 10.1053/j.seminhematol.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/27/2023]
Abstract
Recent advances in the understanding of Waldenström macroglobulinemia (WM) biology have impacted the development of effective novel agents and improved our knowledge of how the genomic background of WM may influence selection of therapy. Consensus Panel 7 (CP7) of the 11th International Workshop on WM was convened to examine the current generation of completed and ongoing clinical trials involving novel agents, consider updated data on WM genomics, and make recommendations on the design and prioritization of future clinical trials. CP7 considers limited duration and novel-novel agent combinations to be the priority for the next generation of clinical trials. Evaluation of MYD88, CXCR4 and TP53 at baseline in the context of clinical trials is crucial. The common chemoimmunotherapy backbones, bendamustine-rituximab (BR) and dexamethasone, rituximab and cyclophosphamide (DRC), may be considered standard-of-care for the frontline comparative studies. Key unanswered questions include the definition of frailty in WM; the importance of attaining a very good partial response or better (≥VGPR), within stipulated time frame, in determining survival outcomes; and the optimal treatment of WM populations with special needs.
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Affiliation(s)
- C S Tam
- Alfred Health, Monash University, Melbourne, Victoria, Australia.
| | | | - J J Castillo
- Harvard Medical School, Dana Farber Cancer Institute, Boston. MA
| | - C Buske
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | | | | | - E Kimby
- Karolinska Institut, Stockholm, Sweden
| | - Y Li
- Baylor College of Medicine, Houston, TX
| | - M L Palomba
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - L Qiu
- National National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - M Shadman
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA
| | | | - S Sarosiek
- Harvard Medical School, Dana Farber Cancer Institute, Boston. MA
| | - Jmi Vos
- Department of Hematology, Cancer Center Amsterdam/LYMMCARE, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Yi
- National National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin 301600, China
| | - D Stephens
- University of Utah Huntsman Cancer Institute, Salt Lake City, UT
| | - D Roos-Weil
- Sorbonne University, Hematology Unit, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | | | - P Morel
- Hematologie Clinique et Therapie Cellulaire, University Hospital Amiens Picardie, University of Picardie Jules Verne, France
| | - N C Munshi
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - K C Anderson
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - J San-Miguel
- Clinica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Navarra, Spain
| | - R Garcia-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
| | - M A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - S P Treon
- Institute of Experimental Cancer Research, University Hospital Ulm, Ulm, Germany
| | - M J Kersten
- Tianjin Institutes of Health Science, Tianjin 301600, China
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Abstract
Waldenström Macroglobulinemia (WM) is a unique, low grade, IgM lymphoplasmacytic lymphoma with a heterogeneous clinical course. A paucity of high-grade evidence from large phase 3 trials remains a major issue in the field despite a rapidly expanding therapeutic armamentarium against WM. Prior knowledge of the patients' MYD88L265P and CXCR4 mutation status aids in treatment decision making if Bruton's tyrosine kinase (BTK) inhibitor therapy is being considered. Head-to head comparative data to inform optimal approach are lacking, and a particularly vexing issue for the clinicians is choosing between fixed-duration bendamustine-rituximab (BR) therapy and an indefinite BTK inhibitor-based regimen, given that both approaches are well tolerated and effective, particularly for the patient population harboring MYD88L265P mutation. For the patients with MYD88WT genotype, chemo-immunotherapy such as BR is preferred, although zanubrutinib, a potent second generation BTK inhibitor, with its reduced off target effects and greater BTK occupancy compared to its predecessor, ibrutinib, has also recently shown activity in MYD88WT WM. This review summarizes the current literature pertaining to the diagnosis, prognosis, and the treatment of WM.
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Affiliation(s)
- Gayathri Ravi
- Division of Hematology Mayo Clinic, Rochester, MN, United States of America
| | - Prashant Kapoor
- Division of Hematology Mayo Clinic, Rochester, MN, United States of America.
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Abstract
PURPOSE OF REVIEW Recent advances the genomic profiling of patients with Waldenström macroglobulinemia (WM) have led to the identification of novel therapeutic targets in these patients. In this review, we cover the current standard of care and the recently evaluated novel approaches with high potential to be incorporated in the therapeutic armamentarium against WM. RECENT FINDINGS The MYD88L265P mutation is the most common genomic abnormality in WM, and is encountered in 80-95% of patients, making it an important target for drug development. The success of the first-generation Bruton tyrosine kinase (BTK) inhibitor, ibrutinib, has generated tremendous interest in the study of more selective and potent BTK inhibitors. Additionally, the identification of CXCR4WHIM mutations in up to approximately 40% of patients with WM has fueled research regarding their implication on systemic therapy in WM. In a rapidly advancing field of targeted therapies, the treatment options for patients with WM are expanding as researchers continue to uncover and harness the survival pathways active in this hematologic malignancy.
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