Lymphoma

Further prospective clinical trials in very elderly patients with DLBCL are clearly needed. Complementing the growing need for such trials, an evolving clinical trial infrastructure, geriatric oncology support, and novel therapeutics are making such studies feasible in the current era.

Patients should ideally undergo very thoughtful evaluation with tools such as the comprehensive geriatric assessment or something similar that will give the treating physician the best estimate of therapy tolerance. Once therapy is initiated, very frequent monitoring is useful for providing early support of toxicity and for most promptly and effectively informing appropriate dose adjustments to ensure optimal dosing.

Elderly patients may have several such comorbidities, but their impact on normal life is minimal-and so most of these patients may receive a curative treatment such as R-CHOP. Very elderly patients have more comorbidities with greater impact, with the result that some of their vital organs exhibit functional deficiency.

In this review, we critically analyze clinical trials that were specifically designed for the very elderly, and we discuss the challenges encountered by investigators who are conducting studies in this patient population. We conclude by proposing an algorithm to help clinicians determine the optimal therapeutic strategy for treatment of DLBCL in very elderly patients.

It is hard to realize that an elderly patient's visit to you is likely the only trip outside his or her apartment for the week and the only contact with someone other than family or an aide. Doctor visits sometimes become the elderly's primary contact with the larger world.

The US Food and Drug Administration has approved imatinib (Gleevec) for the treatment of newly diagnosed Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph+ ALL) in children.

The combination of two antibody-based targeting agents-inotuzumab ozogamicin and rituximab-demonstrated high response rates and long progression-free survival in patients with relapsed follicular lymphoma or relapsed diffuse large-B-cell lymphoma (DLBCL) in an international phase I/II multicenter, open-label study.

Researchers have identified an enzyme that plays an important role in the reprogramming of malignant progenitor cells in chronic myeloid leukemia. The enzyme, ADAR1, could represent a target for selecting and eradicating leukemia stem cells.

In this interview we discuss the latest chronic myeloid leukemia treatment and research with Dr. Michael Deininger, chief of the division of hematology at the University of Utah School of Medicine.

The current standard therapies for chronic lymphocytic leukemia do not prevent Richter's transformation from occurring. If we are fortunate, new treatments will realize the hope that this usually fatal complication of chronic lymphocytic leukemia might be avoided.

It is time to move on to next key steps of improving recognition of treatment-resistant lymphoma at diagnosis, rather than at treatment failure, by optimally employing biomarkers and improving cure rates by integrating powerful but minimally toxic new systemic agents into primary treatment.

The likelihood that combined-modality therapy will provide a small progression-free survival advantage is real but not likely to be equated to an overall survival advantage, as it depends on when one looks at the data. The studies to date demonstrate a late fall-off in survival due to one or another toxic effect of radiation.

In Hodgkin lymphoma, as with many other malignancies, a combined-modality approach has proven successful. This tactic capitalizes on the relative advantages of both modalities, yet minimizes risk by avoiding intense exposure to either. This article will summarize the data supporting this approach in early-stage Hodgkin lymphoma.

The US Food and Drug Administration has approved ponatinib (Iclusig) to treat adults with chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia.

A combination of all-trans retinoic acid (ATRA) and arsenic trioxide resulted in outcomes “at least not inferior” to those achieved when ATRA was used in combination with idarubicin chemotherapy in newly diagnosed patients with non–high-risk, acute promyelocytic leukemia.

The combination of rituximab and the novel immunotherapy pidilizumab (CT-011) is both active and well tolerated in follicular lymphoma patients according to results of a phase II trial presented at ASH.

Relapsed or refractory chronic lymphocytic leukemia and acute lymphoblastic leukemia patients have shown durable responses of almost 2 years to a novel T-cell engineering technique developed at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Updated findings from the pivotal phase II PACE trial show sustained benefit of the investigational BCR-ABL tyrosine kinase inhibitor ponatinib in heavily pretreated patients with resistant or intolerant chronic myeloid leukemia or Philadelphia chromosome-positive acute lymphoblastic leukemia.

Final results of a cohort from a phase II monotherapy trial of quizartinib in acute myeloid leukemia patients showed that more than half of patients 60 years of age and older who harbored an internal tandem duplication in the FMS-like tyrosine kinase 3 had a composite complete remission.

Despite a better major molecular response rate, the Src/Abl tyrosine kinase inhibitor bosutinib did no better than imatinib with regard to complete cytogenetic response in the BELA trial of patients with newly diagnosed chronic myeloid leukemia (CML).

The second generation tyrosine kinase inhibitor nilotinib (Tasigna, Novartis) has proven to be an effective treatment for imatinib-resistant patients with chronic myeloid leukemia (CML). Just as with imatinib, however, some resistance has been observed.

The FDA today approved omacetaxine mepesuccinate (Synribo) for the treatment of adults with chronic myeloid leukemia (CML) who are resistant to other therapies.

A new review of the literature shows that melanoma is substantially more common in immunosuppressed patients, including those with prior solid organ transplant and individuals with lymphoma.

Physicians now have the luxury of focusing attention on maximizing outcomes that are already quite favorable, and of devoting more attention to improving quality of life and addressing questions of cost-effectiveness.

Resistance due to new mutations in the genes coding for the targeted proteins, as well as to changes in other signaling pathways, often develops, and newer drugs and perhaps combination approaches may be needed.

Is it reasonable to start all new CML patients on treatment with imatinib alone and continue the drug indefinitely in those who fare well, or should one start treatment with one of the newer agents or possibly with imatinib in combination with another anti-CML agent in order to secure the best possible outcome for an individual patient?

Ariad Pharmaceuticals followed last month’s request to the FDA for accelerated approval of the BCR-ABL inhibitor ponatinib with a similar request to the European Medicines Agency.

The most interesting developments in drug therapy for adult ALL are occurring in two fields: (1) molecularly targeted therapies and (2) the use of antibodies, conjugated antibodies, or antibody constructs.

It is clear that the management of adult patients with ALL is an area in which little progress has been made in the last 30 years. Given the disappointing outcomes, the field is one that lends itself to the study of the incorporation of novel agents, including monoclonal antibodies and tyrosine kinase and proteasome inhibitors, as well as to further study of allogeneic transplant.

In this review, we will discuss the management of ALL in the adult population, in the context of the recently published guidelines from the NCCN. We will focus in particular on the strides being made in salvage and targeted approaches.