Dr. Neha Mehta-Shah, associate professor in the John T. Milliken Department of Medicine in the Division of Oncology at Washington University Medical School in St. Louis, recently highlighted several promising developments in the treatment landscape for rare lymphomas, emphasizing advancements that could significantly improve patient outcomes.
"There are many agents currently being studied that are promising in rare lymphomas," noted Dr. Mehta-Shah in an interview with CancerNetwork®. Her insights reveal a rapidly evolving field with several therapeutic approaches showing particular promise.
Targeted Therapies for T-Cell Lymphomas
Among the most encouraging developments are PI3K inhibitors and EZH2 inhibitors for T-cell lymphomas. These agents have consistently demonstrated efficacy across multiple clinical trials, even in patients who failed to respond to standard chemotherapy regimens.
"The studies now consistently across multiple drugs in the same class, for both types, seem to show that these drugs are efficacious, even when chemotherapy or other standard agents have not been efficacious," Dr. Mehta-Shah explained. This is particularly significant for patients with T-cell lymphomas, who have "particularly few options for standard treatment, nationally and internationally."
These targeted therapies represent a major advancement in treating rare lymphoma subtypes like cutaneous T-cell lymphoma, where treatment options have historically been limited.
Novel Antibody Approaches
Another promising area involves novel antibodies targeting KIR3DL2, which have shown durable remissions with improved quality of life. This is especially important for patients with rare lymphomas who often experience significant impairment in quality of life due to both their disease and treatments.
"We are excited about this novel class of medicines in that arena," Dr. Mehta-Shah emphasized, highlighting the potential for these antibody therapies to address both disease control and patient well-being.
Immunotherapy in Hodgkin Lymphoma
Immunotherapy integration in Hodgkin lymphoma treatment represents another significant advancement. The phase 3 S1826 trial (NCT03907488) demonstrated that nivolumab (Opdivo) combined with doxorubicin, vinblastine, and dacarbazine (AVD) provided progression-free survival benefits compared to brentuximab vedotin (Adcetris) with AVD.
This finding is particularly important because Hodgkin lymphoma often affects young adults. "As we have gotten better at treating and curing some of these patients, we are trying to develop treatments that have fewer adverse effects long term and do not increase their risk of other health care events like heart attack, strokes, breast cancer, and other cancers," Dr. Mehta-Shah said.
Current research is now focused on how to potentially de-escalate therapy while maintaining efficacy. A U.S. intergroup study (NCT06745076) is examining early-stage Hodgkin lymphoma patients, incorporating brentuximab vedotin and nivolumab earlier in treatment. This study is measuring not only survival but also survivorship and quality of life.
Diagnostic Advances Enabling Targeted Treatment
The advancement of diagnostics has played a crucial role in better identifying rare lymphoma subtypes and developing therapies that target specific biomarkers. Genomic testing has enabled investigators to develop and assess drugs that selectively target the epigenome to elicit better efficacy for rare lymphomas.
"One big category of those is in diagnosis," Dr. Mehta-Shah explained. "There have been advances in the ability to use things like mutational profiling or genetic sequencing of cancer cells, that have helped to refine the diagnosis of rare diseases."
This improved diagnostic capability has led to better understanding of disease biology and subsequent development of both intravenous and oral therapies for these rare cancers.
Challenges in Rare Lymphoma Research and Treatment
Despite these advances, significant challenges remain in treating rare lymphomas. Dr. Mehta-Shah highlighted the paucity of data compared with more common cancer types, and a reliance on findings from related diseases, subgroup analyses, or expert consensus guidelines to inform research.
"In rare diseases, more specifically rare lymphomas, sometimes the whole study to help inform a patient's therapy could have been 15 to 30 patients, and all those patients received the same therapy," she noted. This makes it difficult to directly compare treatment options.
Additionally, the diagnostic process for rare lymphomas can be challenging and time-consuming. "It often takes a longer time to make the diagnosis as some may have never seen this disease before. We usually have to send the biopsies off to an expert laboratory, academic medical center, or reference laboratory, and that can often take weeks," Dr. Mehta-Shah explained.
Future Directions
Looking ahead, Dr. Mehta-Shah emphasized the importance of dynamic personalized medicine monitoring, including the use of minimal residual disease (MRD) assessment and cell-free DNA (cfDNA) analysis to guide treatment decisions.
"Trials using dynamic monitoring, using cfDNA to decide to evaluate whether escalation of therapy to either other chemotherapy, stem cell transplantation, bispecific antibodies, or CAR T cells is warranted for people who were MRD-positive at the end of treatment or have insufficient decline in their cfDNA," she noted.
The development of these therapeutic approaches, combined with improved diagnostic capabilities and personalized monitoring, offers new hope for patients with rare lymphomas who have historically had limited treatment options.
