Richter s Syndrome: Risk, Predictors and Treatment

Transcription

1 Richter s Syndrome: Risk, Predictors and Treatment 10/23/2015 John N. Allan MD Assistant Professor of Medicine Division of Hematology and Medical Oncology CLL Research Center Weill Cornell Medicine

2 Agenda Richter s Syndrome (RS) Background Epidemiology Clinical and Biological Risk Factors Comparison CLL->RS Comparison to de novo DLBCL Clinical Predictors of Outcome to Therapy Impact of Transplantation RS in era of Novel Agents New Directions

3 Background First described in 1928 by Maurice Richter, MD Professor of Pathology (Columbia and NYU) Chairman Richter s Syndrome (RS) is coined years later in 1964 Am J Pathol, (4): p Our Dermatol Online. 2013; 4(3):

4 Richter s Transformation Statistics Term should be restricted to CLL transformations 90% -> DLBCL >90% are of the non-gcb subtype ~60-80% are clonally related >80% lack association with EBV ~10%->Hodgkin Variant (HVRS) Outcomes are worse than de novo HL, better than transformed DLBCL 3.9 yrs median OS ABVD remains standard 10 yr risk is about 0.5% at 10 years ~70% EBV positive Parikh et al. Am J Hematol Apr;90(4):334-8

5 Annual Incidence Rate Parikh et al Br J Haematol September ; 162(6):

6 Clinical and Biological Risk Factors for Transformation Common Biological Predictors when corrected for Rai Stage Parikh et al. Br J Haematol Sep; 162(6): Effect of Chemotherapy: Univariate Drug Class Purine analogue without alkylating agent Alkylating agent without purine analogue Combination therapy of purine analogue and alkylating agent Odds Ratio for Developing RS p-value 0.72 ( ) ( ) ( ) Alemtuzumab +/- Rituximab 2.15 ( ) 0.21 Telomere Length Clinical Risk Factors: Multivariate Analysis with multiple factors Parikh et al. Br J Haematol Sep; 162(6): Clinical variables Lymph node size 3 cm Biological and clinical variables Lymph node size 3 cm HR 95% CI P < No del13q Rossi et al. Br J Haematol Jun;142(2): Rossi et al Leukemia Jun;23(6):

7 IgH stereotypy, IgHV gene usage and Transformation risk C. Rossi et al Clin Cancer Res Jul 1;15(13):

8 Notch1 Mutations Increase RS Risk Rossi et al. Br J Haematol Aug;158(3):426-9.

9 Comparison RS to CLL Fabbri et al J Exp Med Oct 21;210(11): Mutational Differences Cytogenetics Promoter Methylation Differences Fabbri et al J Exp Med Oct 21;210(11): Rinaldi et al Br J Haematol Oct;163(2):

10 Comparison to De Novo DLBCL Mutational Profiling Promoter Methylation Profiling Fabbri et al J Exp Med Oct 21;210(11): Rinaldi et al Br J Haematol Oct;163(2):

11 Predictors of Outcome to Therapy: Clonality and RS Score Risk Factors RR P Performance status (0 or 1 v 2-4) Lactate dehydrogenase (< 1.5 normal v > 1.5 normal) Platelet count (> /L v < /L) Tumor size (< 5 cm v > 5 cm) Prior therapies (0-1 v > 1) Tsimberadou et al.j Clin Oncol May 20;24(15): Rossi et al. Blood Mar 24;117(12):

12 Chemo immunotherapy Regimens for RS: Parikh et al Blood Mar 13;123(11):

13 Impact of Stem Cell Transplantation on RS N=20 Autologous Transplant N=35 Allogeneic Transplant N=20 Tsimberidou et al. J Clin Oncol May 20;24(15): Kate Cwynarski et al. JCO 2012;30:

14 Outcomes After Allogeneic Transplant Failure: SCT performed for RS Uri Rozovski et al. JCO 2015;33: Uri Rozovski et al. JCO 2015;33:

15 Ibrutinib Failure and RS Maddocks et al. JAMA Oncol. 2015;1(1): Farooqui et al Lancet Oncol Feb;16(2):169-76

16 New Directions Need for Novel Targeted Agents Current Available Clinical Trials allowing RS or designed specifically for RS KPT-330 (selinexor)-xpo1 Inhibitor PNT2258-Liposomal encapsulated DNA oligonucleotide targeting BCL-2 CC-486 (oral azacytidine)+rchop ACP-196 ACP Pembrolizumab CART cells

17 Summary RS is a distinct biological entity from de novo DLBCL and other transformed lymphomas Transformation is associated with specific recurrent mutational, chromosomal and promoter methylation changes compared to paired CLL samples Clinical, biological and genomic information is now established for RS risk factors and predictors of outcome Current chemo immunotherapy paradigms are relatively ineffective Transplantation can improve outcomes however few patients (~10-15%) are eligible (comorbidities, response etc) Few targeted approaches are available, but have proven effective in achieving responses in refractory patients.

18 John N. Allan MD Assistant Professor of Medicine Division of Hematology and Medical Oncology CLL Research Center Weill Cornell Medicine