Canadian evidence-based guideline for frontline treatment of chronic lymphocytic leukemia: 2022 update

Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In 2018, the first unified national guideline in Canada was developed for the front-line treatment of cll that helped guide treatment across the country. As an update in 2022, a group of clinical experts from across Canada came together to provide input and guidance that included new and innovative treatments and approaches that will continue to provide health care professionals with clear guidance on the first-line management of cll. Recommendations were provided in consensus based on available evidence for the first-line treatment of cll.

TCL-323 Outcome of Relapsed and Refractory Peripheral T-Cell Lymphoma (PTCL) With Intention for Curative Therapy Incorporating High-Dose Chemotherapy and Hematopoietic Stem Cell Transplant (HDC/SCT)

INTRODUCTION

Salvage therapy with high-dose chemotherapy and hematopoietic stem cell transplant (HDC/SCT) is recommended for patients with relapsed/refractory (R/R) PTCL. We evaluated the outcomes of R/R PTCL from the time of first relapse/progression in patients intended for SCT (ITT).

METHODS

The BC Cancer Lymphoid Cancer Database was reviewed, and patients ≥18 years with R/R PTCLs, such as systemic anaplastic large cell lymphoma (ALCL), angioimmunoblastic T-cell lymphoma (AITL), and PTCL-not otherwise specified (PTCL-NOS), were included. Outcomes were assessed from the time of first relapse/progression and from the time of SCT.

RESULTS

Of 114 included patients with ITT R/R PTCL, 60% had refractory disease and were more likely to have a high secondary IPI score, poor performance status, or advanced-stage disease. For second-line therapy, the majority received multi-agent chemotherapy (n = 83, 73%) with GDP, (gemcitabine, dexamethasone, and cisplatin) the most used regimen (n = 59, 52%), whereas 15 patients (13%) received novel agents (brentuximab vedotin [BV] = 12; romidepsin=2; pralatrexate=1). The overall response rate (ORR) to second-line therapy was 61% (24% complete response [CR]; 37% partial response [PR]). The ORR to GDP was 61% (17% CR; 44% PR), with higher responses observed in relapsed patients (81% vs. 41%, p=0.002). Seventy-three patients (63%) received HDC/SCT. Those who underwent allo-SCT were younger and more likely to have refractory disease (50% vs. 16%, p=0.001). Third-line therapy was required in 17/67 (25%), including novel agents in 9 cases. The median follow-up for living patients was 6.8 years. The 5-year progression-free survival (PFS) and overall survival (OS) from the time of first relapse/progression were 28% and 38%, respectively. The 5-year PFS from auto and allo-SCT were 34% and 52% (p = 0.3), and 5-year OS were 44% and 67% (p=0.5), respectively.

CONCLUSIONS

Overall, outcomes for patients with ITT R/R PTCL remain suboptimal, with long-term survival in only one-third of patients; however, over half remained alive at 5 years if they were able to receive an SCT. A third line of therapy may serve as a successful bridge to SCT, and novel agents should be considered. Despite a higher proportion of refractory patients, results are encouraging with allo-SCT.

Real-world incidence of venetoclax toxicities in British Columbia

Introduction

Venetoclax is used to treat relapsed/refractory chronic lymphocytic leukemia (r/r CLL). Tumour lysis syndrome (TLS) is a serious toxicity associated with venetoclax, and real-world studies suggest that the incidence may be higher than in clinical trials. The purpose of this study is to describe the incidence of venetoclax toxicities in British Columbia (BC).

Methods

Retrospective review of electronic medical charts for patient characteristics and clinical outcomes of patients treated with venetoclax for r/r CLL in BC. Patients were classified according to their risk for developing TLS. The incidence of TLS was categorized based on laboratory metrics or clinical diagnosis. Other non-TLS toxicities were also collected.

Results

Of 33 patients identified, 40%, 33%, and 27% were at low, intermediate, and high risk for TLS, respectively. Laboratory TLS occurred in 1/33 patients (3%), and no clinical TLS was reported. Grade 3 or 4 toxicities occurred in 19/33 patients (58%). Of these, neutropenia was the most common, occurring in 16 patients (84%) followed by thrombocytopenia, which occurred in 8 patients (42%).

Conclusions

The incidence of TLS in patients treated with venetoclax for r/r CLL in BC was lower than in other real-world studies. Findings may warrant further investigation to determine if the higher incidence of TLS in real-world reports may be mitigated through modifying TLS risk categorization and associated prophylactic measures. Neutropenia was the most common grade 3 or 4 venetoclax toxicity reported, and the incidence in BC is comparable to other centres.

Mortality from Multiple Myeloma Within One Year Following Autologous Stem Cell Transplantation: Defining an Ultra-high Risk Population

Despite improvements in therapy, approximately 5% of patients who undergo autologous stem cell transplantation (ASCT) experience early mortality (EM), death within 1 year of transplant (EM post-ASCT). Such patients tend to have few comorbidities suggesting their EM is owing to aggressive underlying disease. We sought to characterize this ultra-high risk population through a retrospective review of patients with newly diagnosed multiple myeloma (MM) treated with first-line ASCT. Patients who died within 1 year of ASCT were matched for age, sex, and year of transplant in a 1:2 fashion with a control group. Of 962 transplants performed between January 1, 2007, and May 1, 2019, 41 patients (4.3%) died within 1 year of ASCT from MM-related causes. In a multivariate analysis, anemia, hypercalcemia, high-risk cytogenetics, and elevated lactate dehydrogenase were associated with EM post-ASCT. Forty patients (97.6%) received at least 1 novel agent. Most patients with EM post-ASCT received second-line chemotherapy (80.5%), although survival from initiation of second-line chemotherapy was only 2.1 months. The primary reason for not receiving second-line therapy was rapid relapse. Clinical parameters reflecting disease burden, as well as high-risk cytogenetics, are associated with EM post-ASCT. These patients have a dismal overall survival despite significant advances in treatment of patients with relapsed or refractory myeloma. Further study of these ultra-high risk patients is required to improve disease management and may give further insights into the biology of relapse and resistance in myeloma.

Comparison of a pediatric-inspired treatment protocol versus standard-intensity chemotherapy for young adults with standard-risk BCR-ABL negative acute lymphoblastic leukemia

We investigated the utility of a pediatric-inspired protocol in adults aged 18-40 years with standard-risk BCR-ABL negative acute lymphoblastic leukemia (ALL). Retrospective outcomes of 25 patients treated with a pediatric protocol between 2008 and 2014 were compared with 22 similarly aged patients treated with an adult protocol between 2003 and 2008. Twenty-five (100%) and 19 (86%) patients achieved complete remission, respectively. At median follow-up of 36.8 months, 3-year event-free survival was increased in patients on the pediatric protocol at 80% versus 45% (p = .019). There was a trend toward improved overall survival at 80% versus 59% (p = .12). Treatment-related toxicity was not increased despite the increased treatment intensity. Patients with BCR and/or ABL copy number variation demonstrated comparatively poorer outcomes in both cohorts. In our experience with this cohort of patients, pediatric-based protocols are safe and effective, justifying their use in younger adults with ALL.

Impact of time from diagnosis to initiation of curative chemotherapy on survival of patients with diffuse large B-cell lymphoma

Although it is generally regarded appropriate to start chemotherapy promptly after a diagnosis of diffuse large B-cell lymphoma (DLBCL), the optimal time from diagnosis to treatment (TDT) is unknown. A total of 689 patients diagnosed with DLBCL and treated with ≥ 1 cycle of CHOP-R with curative intent during 2003-2008 in British Columbia were identified: 347 (50%) TDT ≤ 4 weeks, 277 (40%) TDT 5-8 weeks, 65 (10%) TDT > 8 weeks. For the respective TDT groups, 5-year OS estimates were 61%, 74%, 63% (p = 0.006); 5-year PFS 57%, 70%, 61% (p = 0.006); and 5-year DSS 64%, 80%, 77% (p <0.001). In multivariate analysis, TDT >8 weeks was associated with worse OS (HR 1.20 (95% CI 1.03, 1.41), p = 0.020), PFS (HR 1.33 (95% CI 1.15, 1.54), p < 0.001), and DSS (HR 1.40 (95% CI 1.10, 1.78), p = 0.006). Clinicians should endeavor to initiate curative chemotherapy as soon as possible after a diagnosis of DLBCL is established.

Effect of place of residence and treatment on survival outcomes in patients with diffuse large B-cell lymphoma in British Columbia

BACKGROUND

We examined the relationship between location of residence at the time of diagnosis of diffuse large B-cell lymphoma (DLBCL) and health outcomes in a geographically large Canadian province with publicly funded, universally available medical care.

PATIENTS AND METHODS

The British Columbia Cancer Registry was used to identify all patients 18-80 years of age diagnosed with DLBCL between January 2003 and December 2008. Home and treatment center postal codes were used to determine urban versus rural status and driving distance to access treatment.

RESULTS

We identified 1,357 patients. The median age was 64 years (range: 18-80 years), 59% were male, 50% were stage III/IV, 84% received chemotherapy with curative intent, and 32% received radiotherapy. There were 186 (14%) who resided in rural areas, 141 (10%) in small urban areas, 183 (14%) in medium urban areas, and 847 (62%) in large urban areas. Patient and treatment characteristics were similar regardless of location. Five-year overall survival (OS) was 62% for patients in rural areas, 44% in small urban areas, 53% in medium urban areas, and 60% in large urban areas (p = .018). In multivariate analysis, there was no difference in OS between rural and large urban area patients (hazard ratio [HR]: 1.0; 95% confidence interval [CI]: 0.7-1.4), although patients in small urban areas (HR: 1.4; 95% CI: 1.0-2.0) and medium urban areas (HR: 1.4; 95% CI: 1.0-1.9) had worse OS than those in large urban areas.

CONCLUSION

Place of residence at diagnosis is associated with survival of patients with DLBCL in British Columbia, Canada. Rural patients have similar survival to those in large urban areas, whereas patients living in small and medium urban areas experience worse outcomes.