Treatment of patients with diffuse large B-cell lymphoma

W ostatniej dekadzie odnotowano istotne zwiększenie możliwości terapeutycznych u chorych z chłoniakami rozlanymi z dużych komórek B (DLBCL). W randomizowanych badaniach klinicznych wykazano, że dodanie rytuksymabu do schematu cyklofosfamid, winkrystyna, doksorubicyna, prednizon (CHOP), stosowanego co 3 tygodnie (R-CHOP) przyczyniło się do wydłużenia czasu przeżycia wszystkich badanych grup chorych bez nasilenia toksyczności. Inna strategia, polegająca na skróceniu odstępu pomiędzy kolejnymi cyklami CHOP do 2 tygodni (CHOP-14), również wydaje się możliwa do zastosowania u wszystkich chorych w wieku 18–75 lat, ale prawdopodobnie nie jest bardziej skuteczna niż R-CHOP-21. Strategie zwiększające intensywność dawki są obecnie badane z intencją poprawy wyników leczenia u młodszych chorych z DLBCL o wysokim ryzyku. U chorych w starszym wieku poprawy wyników leczenia można się spodziewać po dołączeniu innych leków do schematu R-CHOP. W przypadku niewystępowania ciężkich chorób towarzyszących jest to wciąż zalecany schemat leczenia w tej grupie wiekowej.In the last 10 years, options for treating patients with diffuse large B-cell lymphoma (DLBCL) have greatly expanded. In randomized clinical studies, the addition of rituximab to cyclophosphamide, vincristine, doxorubicin, prednisone (CHOP) delivered every 3 weeks (R-CHOP) has been associated with improved survival rates, without increased toxicity, in all patient groups studied. Another strategy, giving patients dose-dense CHOP - CHOP every 2 weeks or CHOP-14 - has also been found appropriate for all patients between the ages of 18 and 75 years but probably not superior to R-CHOP-21. Strategies with dose-intense regimens are currently tested for improving the outcome of young patients with poor risk DLBCL. In elderly patients, improvement in outcomes might be caused by the addition of another drug to the R-CHOP regimen. Elderly patients are best treated with R-CHOP if they do not have severe concomitant diseases

Compromising the Unfolded Protein Response Induces Autophagy-Mediated Cell Death in Multiple Myeloma Cells

OBJECTIVE: To determine whether the Unfolded Protein Response (UPR) sensors (PERK, ATF6 and IRE-1) can be targeted to promote death of Multiple Myeloma (MM) cells. METHODS: We have knocked-down separately each UPR stress sensor in human MM cell lines using RNA interference and followed MM cell death by monitoring the membrane, mitochondrial and nuclear alterations. Involvement of caspases in MM cell death consecutive to UPR sensor knock-down was analyzed by western blotting, measurement of their enzymatic activity using fluorigenic substrates and susceptibility to a pan-caspase inhibitor. Activation of the autophagic process was measured directly by detection of autophagosomes (electronic microscopy), monodansylcadaverine staining, production of the cleaved form of the microtubule-associated protein 1A/1B light chain 3 (LC3) and indirectly by analyzing the impact of pharmacological inhibitors of autophagy such as 3MA and bafilomycin A1. RESULTS: We show that extinction of a single UPR stress sensor (PERK) induces a non-apoptotic form of cell death in MM cells that requires autophagy for its execution. We also show that this cytotoxic autophagic process represses the apoptosis program by reducing the cytosolic release of the apoptogenic factors Smac/DIABLO and cytochrome c. INTERPRETATION: Altogether our findings suggest that autophagy can contribute to execution of death in mammalian cells that are exposed to mild ER stress. They also suggest that the autophagic process can regulate the intrinsic apoptotic pathway by inhibiting production of death effectors by the mitochondria, thus preventing formation of a functional apoptosome. Altogether these findings give credit to the idea that UPR sensors can be envisaged as therapeutic targets for the treatment of MM

Dabrafenib plus trametinib in patients with relapsed/refractory BRAF V600E mutation–positive hairy cell leukemia

BRAF V600E is the key oncogenic driver mutation in hairy cell leukemia (HCL). We report the efficacy and safety of dabrafenib plus trametinib in patients with relapsed/refractory BRAF V600E mutation–positive HCL. This open-label, phase 2 study enrolled patients with BRAF V600E mutation–positive HCL refractory to first-line treatment with a purine analog or relapsed after ≥2 prior lines of treatment. Patients received dabrafenib 150 mg twice daily plus trametinib 2 mg once daily until disease progression, unacceptable toxicity, or death. The primary endpoint was investigator-assessed objective response rate (ORR) per criteria adapted from National Comprehensive Cancer Network-Consensus Resolution guidelines. Secondary endpoints included duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety. Fifty-five patients with BRAF V600E mutation–positive HCL were enrolled. The investigator-assessed ORR was 89.0% (95% confidence interval, 77.8%-95.9%); 65.5% of patients had a complete response (without minimal residual disease [MRD]: 9.1% [negative immunohistochemistry of bone marrow {BM} biopsy], 12.7% [negative BM aspirate flow cytometry {FC}], 16.4% [negative immunohistochemistry and/or FC results]; with MRD, 49.1%), and 23.6% had a partial response. The 24-month DOR was 97.7% with 24-month PFS and OS rates of 94.4% and 94.5%, respectively. The most common treatment-related adverse events were pyrexia (58.2%), chills (47.3%), and hyperglycemia (40.0%). Dabrafenib plus trametinib demonstrated durable responses with a manageable safety profile consistent with previous observations in other indications and should be considered as a rituximab-free therapeutic option for patients with relapsed/refractory BRAF V600E mutation–positive HCL. This trial is registered at www.clinicaltrials.gov as #NCT02034110.</p

Rituximab plus bendamustine or chlorambucil for chronic lymphocytic leukemia: primary analysis of the randomized, open-label MABLE study

MABLE investigated the efficacy and safety of rituximab plus bendamustine or rituximab plus chlorambucil in fludarabine-ineligible patients with chronic lymphocytic leukemia. Patients received rituximab plus bendamustine or rituximab plus chlorambucil every four weeks for six cycles. Rituximab plus chlorambucil-treated patients without a complete response after Cycle 6 received chlorambucil monotherapy for at least six additional cycles or until complete response. The primary endpoint was complete response rate (confirmed by bone marrow biopsy) after Cycle 6 in first-line patients. Secondary endpoints included progression-free survival, overall survival, minimal residual disease, and safety. Overall, 357 patients were randomized (rituximab plus bendamustine, n=178;rituximab plus chlorambucil, n=179;intent-to-treat population), including 241 first-line patients (n=121 and n=120, respectively);355 patients received treatment (n=177 and n=178, respectively;safety population). In first-line patients, complete response rate after Cycle 6 (rituximab plus bendamustine, 24%;rituximab plus chlorambucil, 9%;P=0.002) and median progression-free survival (rituximab plus bendamustine, 40 months;rituximab plus chlorambucil, 30 months;P=0.003) were higher with rituximab plus bendamustine than rituximab plus chlorambucil. Overall response rate and overall survival were not different. In first-line patients with a complete response, minimal residual disease-negativity was higher with rituximab plus bendamustine than rituximab plus chlorambucil (66% vs. 36%). Overall adverse event incidence was similar (rituximab plus bendamustine, 98%;rituximab plus chlorambucil, 97%). Rituximab plus bendamustine may be a valuable first-line option for fludarabine-ineligible patients with chronic lymphocytic leukemia. clinicaltrials.gov identifier: 0105651

High frequency of central nervous system involvement in transformed Waldenstrom macroglobulinemia

Histologicaltransformation (HT) to diffuse large B-cell lymphoma (DLBCL) is a rare event in Waldenström macroglobulinemia (WM) and is associated with a poor prognosis.1-4 It confers an inferior outcome compared with WM patients without HT.2,3 Most transformed WM patients present with elevated serum lactate dehydrogenase (LDH) levels and extranodal disease.1 Among extranodal sites, the central nervous system (CNS) is one of the most frequently involved sites identified at diagnosis of transformed WM (ranging from 13% to 18%).1,3 However, the prognostic value of CNS involvement is unknown, and the rate of CNS involvement at relapse has not been previously reported in this setting.This work was supported by Cancer Research UK [C355/A26819], FC AECC, and AIRC under the “Accelerator Award Program” [EDITOR] to M.A. and R.G.-S

Management of elderly patients with chronic lymphocytic leukemia in the era of targeted therapies

International audienceChronic lymphocytic leukemia (CLL) is frequently diagnosed after 71 years, though median age in published clinical trials with standard chemoimmunotherapy regimens in frontline or relapse setting is mostly below 70 years (58-71 years). Development of oral, less toxic and thus more affordable targeted therapies offers new therapeutic options in those patients deemed unfit for chemotherapy.Recent findingsThis review will discuss results of these new agents in the therapy of elderly patients. Apart from discussing the impact of chronological age, creatinine clearance and cumulative illness rating scale scores in the clinical outcomes, we will also discuss how individualized treatment decision-making should include more precise geriatric assessment tools to thoroughly assess life expectancy, anticipate tolerability, to avoid deleterious stress precipitating prefrail patients into definitive loss of capacity, with dramatic social and economic costs.SummaryIn the era of new targeted agents to fight cancers, we propose concepts to help us understand how elderly dedicated trial designs and geriatric assessment tools (apart from the evaluation of CLL biological risk factors) will undoubtedly revolutionize therapeutic approaches in everyday practice CLL patients

Telephone follow-up of oncology patients: the contribution of the nurse specialist for a Service-Dominant Logic in hospital

International audienceAbstract Background The French healthcare system is characterised by a shift towards outpatient care and the desire to develop telemedicine affirmed in the collective commitment “Ma santé 2022” presented by President Macron in 2018. In France, remote patient follow up has recently been developed in the active phase of cancer treatment inspired by the patient navigation approach used in other countries. According to Service-Dominant Logic (S-D L), patients become more active. Their role in co-production of services is strengthened and their behaviours changed. Telephone follow-ups can contribute to modifying the relationship between the patient and the nurse navigators in charge of it, moving logically from a passive attitude from the patient to a more active one. Methods This study was carried out at Léon Bérard, a cancer control unit, in France. It concerned patients treated in an oncohaematology department, who benefited from telephone follow-ups carried out by nurse specialists during the active phase of their treatment. The multidisciplinary research team including social science researchers, physicians and carers developed a research protocol to study this pilot case. Essentially based on a qualitative approach, it was validated by the centre’s management to study this follow-up on patients’ behaviours. The 1st phase of the research, based on 24 semi-structured interviews with patients undergoing treatment undertaken from November 2018 to September 2019, is presented. Results The Telephone follow-up was a positive experience for all patients. The action of the nurse specialist helped to develop certain dimensions of in-role and extra-role behaviour that created value. The patients’ discourse has reported a positive follow-up in its clinical dimensions, its psychological dimensions and an enhanced quality of life. We detected a patient activation through their roles but it remained limited. The telephone follow-up also created a patient dependency. Conclusions The telephone follow-up is a relevant tool for patients undergoing treatment and it deserves to be more widely deployed. It brings comfort and creates a relationship based on trust but at the same time it limits the emancipation of the patient, which is a central element of the S-D logic and its empowerment

Les effets des configurations territoriales sur les parcours de soins en cancérologie hématologique. L'exemple du CLCC Léon Bérard à Lyon

International audienc

Déchiffrage du code tubuline: Le voile se lève sur le rôle de l’acétylation et de la détyrosination

International audienceLes microtubules sont des fibres du cytosquelette formées par l’assemblage d’hétérodimères d’α- et de β-tubuline. Ils contribuent à l’établissement de la forme des cellules et de leur polarité, ainsi qu’à leur mobilité. Ils jouent aussi un rôle important dans le transport intracellulaire et dans la division cellulaire. Le réseau microtubulaire s’adapte constamment aux besoins de la cellule. Il peut être constitué de microtubules très dynamiques ou d’autres plus stables. Pour moduler dans l’espace et le temps les différentes fonctions de ces fibres, de nombreuses modifications post-traductionnelles réversibles de la tubuline sont mises en jeu, à l’origine de ce qui est maintenant appelé le « code tubuline ». Dans cette revue, nous nous intéresserons au rôle de deux modifications caractéristiques des microtubules stables : l’acétylation et la détyrosination de l’α-tubuline. Nous discuterons également de l’implication de leur dérégulation dans certaines pathologies