Optimizing Treatment of Follicular Lymphoma - Episode 12
Ian Flinn, MD: There are other exciting regimens that are being developed, Pier Luigi. There are data with obinutuzumab and lenalidomide. That’s actually pretty good. What do you think?
Pier Luigi Zinzani, MD, PhD: Yeah, very interesting. Loretta Nastoupil from The University of Texas MD Anderson Cancer Center will present here at ASH [American Society of Hematology 2019 Annual Meeting & Exposition] the preliminary data on 90 untreated patients with follicular lymphoma using this kind of combination. Now it’s an S-square of generation with obinutuzumab plus lenalidomide, and the overall response rate is 98%; the CR [complete response] rate is 92%. So the classical toxicity related to lenalidomide in particular, has faster action regarding neutropenia and thrombocytopenia. But at the end of the day, the data are really preliminary but very, very interesting. So in terms of a new update of chemotherapy regimen is the treatment of follicular lymphoma.
Ian Flinn, MD: Ninety-eight percent? Our work is done. We can go home, right? As always, these are preliminary data and would have to be validated.
Pier Luigi Zinzani, MD, PhD: Only 90 patients there’s a phase II monocenter. So yes.
Ian Flinn, MD: There are biases there, but still.
Pier Luigi Zinzani, MD, PhD: Yeah, could be.
Ian Flinn, MD: But still pretty.
John Gribben, MD, DSc: But we’ve got it in context of thinking now you’ve got lenalidomide you can use with rituximab, you can use it with obinutuzumab, you can use it with a CD19 antibody. So you’re seeing at ASH a whole variety of different partners that are anti-CD20 or anti-CD19 antibodies that are being used, all of which I think demonstrate that using an immunomodulator agent with an antibody makes sense. You’ll then have a choice of which antibody you’ll think about, so we’ll get back into what’s the right order in which we are giving these types of therapy.
Pier Luigi Zinzani, MD, PhD: And in particular without any kind of cumulative toxicity. This is important.
John Gribben, MD, DSc: Yeah.
Ian Flinn, MD: Would it worry you to use a CD19 antibody given the advent of cellular therapy? Does that play in your decision at all? If it was available.
John Gribben, MD, DSc: Yeah, absolutely. If you’ve got a patient who would be coming to CAR Ts [chimeric antigen receptor T-cell therapies], we haven’t got CAR T approved for follicular yet, but they’re coming, and it’s very close. There clinical trials that are available, and I wouldn’t be wanting to close the door for a patient who looks as if they were heading toward needing CAR Ts. Certainly in diffused large B-cell lymphoma, I don’t like to use the CD19-targeted therapy for exactly that reason. I think the same could be true here also.
But there are many sorts of patients we’ve been talking about today who wouldn’t be candidates for a CAR T approach. Patients with lots of comorbidities, CD19-targeted therapies in people who already had lots of exposure to the 2 other antibodies that we talked about already, might just add something else that you have available.
Ian Flinn, MD: What about the addition of checkpoint inhibitors in this setting? Do you think that helps?
Pier Luigi Zinzani, MD, PhD: Yeah, checkpoint inhibitors as a single agent—PEMBRO [pembrolizumab], NIVO [nivolumab]—are not so active. But there was, 2 or 3 years ago, another phase I or phase II study at The University of Texas MD Anderson Cancer Center concerning the combination of pembrolizumab plus rituximab. The preliminary data were quite interesting in terms of overall response rate—more than 60%, with 50% of CR. But they published that it’s not a really good combination for the future because NIVO [nivolumab] and PEMBRO [pembrolizumab] are not very active in the treatment of follicular lymphoma.
Ian Flinn, MD: Got it.
Transcript Edited for Clarity