Bio


Dr. Bita Fakhri is Assistant Professor of Medicine in the Division of Hematology at Stanford University School of Medicine. She specializes in the treatment of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), hairy cell leukemia, and other hematologic malignancies. As a clinical scientist, Dr. Fakhri is dedicated to caring for patients, teaching trainees, and researching novel therapies for patients with CLL/SLL. Dr. Fakhri has co-authored numerous publications on topics including CLL, novel targeted agents, and cellular therapies for patients with hematologic malignancies. Currently, Dr. Fakhri is the director of the CLL clinical trial portfolio at Stanford, and serves on the National Comprehensive Cancer Network CLL panel.

Clinical Focus


  • Hematology
  • clinical trials
  • CLL/SLL
  • hairy cell leukemia
  • PLL
  • indolent lymphomas

Academic Appointments


Honors & Awards


  • Junior Faculty Career Development Award, University of California, San Francisco (2020)
  • Division of Hematology and Oncology Annual Teaching Award, University of California, San Francisco (2021)

Boards, Advisory Committees, Professional Organizations


  • Panel Member, CLL and Hairy Cell Leukemia Guidelines Committee, National Comprehensive Cancer Network (2022 - Present)
  • Panel Member, B Cell Lymphomas Guidelines Committee, National Comprehensive Cancer Network (2019 - 2022)

Professional Education


  • Board Certification, American Board of Internal Medicine, Medical Oncology (2018)
  • Board Certification, American Board of Internal Medicine, Hematology (2018)
  • Board Certification, American Board of Internal Medicine, Internal Medicine (2015)
  • Certificate, Washington University School of Medicine, Clinical Investigation (2018)
  • Fellowship, Washington University School of Medicine, Hematology and Medical Oncology (2018)
  • Residency, Boston University Medical Center, Internal Medicine (2015)
  • MPH, Yale School of Public Health, Epidemiology and Biostatistics (2011)
  • MD, Iran University of Medical Sciences, Medicine (2009)

Clinical Trials


  • Safety and Efficacy Study of Epcoritamab in Subjects With Relapsed/Refractory Chronic Lymphocytic Leukemia and Richter's Syndrome Recruiting

    The study is a global, multi-center safety and efficacy trial of epcoritamab, an antibody also known as EPKINLY™ and GEN3013 (DuoBody®-CD3xCD20). Epcoritamab will either be studied as: - Monotherapy, or - Combination therapy: - epcoritamab + venetoclax - epcoritamab + lenalidomide - epcoritamab + R-CHOP (i.e., rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine and prednisone). The study includes patients with relapsed/refractory chronic lymphocytic leukemia (R/R CLL)/small lymphocytic lymphoma (SLL) and patients with Richter's Syndrome (RS). Study participants with R/R CLL/SLL are treated either with epcoritamab as monotherapy or epcoritamab + venetoclax. Study participants with RS are treated either with epcoritamab as monotherapy or epcoritamab + lenalidomide or epcoritamab + R-CHOP. The trial consists of two parts, a dose-escalation phase (phase Ib) and an expansion phase (phase II). Patients with RS are only included in the expansion phase.

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  • The Combination of Venetoclax and Obinutuzumab in People With Chronic Lymphocytic Leukemia (CLL) Not Recruiting

    This study will help researchers collect more information about how effective the combination of venetoclax and obinutuzumab is in treating CLL in people who have not received a previous treatment for their cancer.

    Stanford is currently not accepting patients for this trial. For more information, please contact Bita Fakhri, MD, 650-498-6000.

    View full details

All Publications


  • Hypertension Treatment in Patients Receiving Ibrutinib: A Multicenter Retrospective Study. Blood advances Samples, L., Voutsinas, J. M., Fakhri, B., Khajavian, S., Spurgeon, S. E., Stephens, D. M., Skarbnik, A. P., Mato, A. R., Broome, C., Gopal, A. K., Smith, S. D., Lynch, R. C., Rainey, M. A., Kim, M. S., Barrett-Campbell, O., Hemond, E., Tsang, M., Ermann, D. A., Malakhov, N., Rao, D., Shakib-Azar, M., Morrigan, B., Chauhan, A., Plate, T., Gooley, T. A., Ryan, K., Lansigan, F., Hill, B. T., Pongas, G., Parikh, S. A., Roeker, L. E., Allan, J. N., Cheng, R., Ujjani, C., Shadman, M. 2024

    Abstract

    Although Bruton's tyrosine kinase inhibitors (BTKis) are generally well-tolerated and less toxic than chemotherapy alternatives used to treat lymphoid malignancies, BTKis like ibrutinib have the potential to cause new or worsening hypertension (HTN). Little is known about the optimal treatment of BTKi-associated HTN. Randomly selected patients with lymphoid malignancies on a BTKi and anti-hypertensive drug(s) and with at least 3 months of follow up data were sorted into two groups: those diagnosed with HTN prior to BTKi initiation (prior-HTN), and those diagnosed with HTN after BTKi initiation (de novo HTN). Generalized estimating equations assessed associations between time varying mean arterial pressures (MAPs) and individual anti-HTN drug categories. Of the 196 patients included in the study, 118 had prior-HTN, and 78 developed de novo HTN. Statistically significant mean MAP reductions were observed in patients with prior-HTN who took beta blockers (BBs) with hydrochlorothiazide (HCTZ), (-5.05 mmHg; 95% CI -10.0 to -0.0596; p = 0.047), and patients diagnosed with de novo HTN who took either an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) with HCTZ (-5.47 mmHg; 95% CI -10.9 to -0.001; p = 0.05). These regimens also correlated with the greatest percentages of normotensive MAPs. Treatment of HTN in patients taking a BTKi is challenging and may require multiple anti-hypertensives. Patients with prior-HTN appear to benefit from combination regimens with BBs and HCTZ, whereas patients with de novo HTN appear to benefit from ACEi/ARBs with HCTZ. These results should be confirmed in prospective studies.

    View details for DOI 10.1182/bloodadvances.2023011569

    View details for PubMedID 38315043

  • Analysis of Treatment Patterns and Outcomes in Patients Ages 60-74 in the PostVenetoclax Era St Martin, E. C., Schwede, M., Fakhri, B., Gotlib, J., Liedtke, M., Shomali, W., Zhang, T. Y., Mannis, G. AMER SOC HEMATOLOGY. 2023
  • A Phase 2 Study of Minimal Residual Disease (MRD)-Adapted Front Line Venetoclax and Obinutuzumab in Fit Patients with Chronic Lymphocytic Leukemia (CLL): Effect of Obinutuzumab on Tumor Lysis Syndrome (TLS) Risk and Safety of Outpatient Venetoclax Dose Escalation Roeker, L. E., Zelenetz, A. D., Park, J. H., Derkach, A., Geyer, M., Islam, P., Falchi, L., Palomba, M., Kumar, A., Salles, G., Lue, J., Goldberg, A. D., Fakhri, B., Coombs, C. C., Falco, V., Panton, G., Tyznar, D., Soni, D., Nogan, L., Lebowitz, S., Blesie, K., Shah, M., Court, S., Jensen, C. E., Mato, A. R., Thompson, M. C. AMER SOC HEMATOLOGY. 2023
  • Pirtobrutinib in Post-cBTKi CLL/SLL: ∼30 Months Follow-up and Subgroup Analysis With/Without Prior BCL2i from the Phase 1/2 BRUIN Study Woyach, J. A., Brown, J. R., Ghia, P., Roeker, L. E., Patel, K., Eyre, T. A., Munir, T., Lech-Maranda, E., Lamanna, N., Tam, C. S., Seymour, J. F., Tessoulin, B., Shah, N. N., Ujjani, C. S., Fakhri, B., Coombs, C. C., Flinn, I. W., Patel, M., Nasta, S. D., Cohen, J. B., Alencar, A. J., Cheah, C. Y., Ma, S., Rhodes, J. M., Jagadeesh, D., Zinzani, P., Osterborg, A., Izutsu, K., Tsai, D. E., Abada, P., Balbas, M., Li, J., Ruppert, A. S., Jurczak, W., Wierda, W. G. AMER SOC HEMATOLOGY. 2023
  • Pirtobrutinib, a Highly Selective, Non-Covalent (Reversible) BTK Inhibitor in Relapsed/Refractory Follicular Lymphoma: Results from the Phase 1/2 BRUIN Study Shah, N. N., Zinzani, P., Wang, M. L., Nasta, S. D., Lech-Maranda, E., Ogawa, Y., Fakhri, B., Kuss, B., Miyashita, K., Patel, K., Coombs, C. C., Ma, S., Patel, M., Barve, M. A., Tessoulin, B., Stathis, A., Kim, W., Ennishi, D., Hashimoto, D., Kojima, K., Zelenetz, A. D., Cohen, J. B., Vose, J. M., Maddocks, K. J., Munir, T., Sun, F., Bian, F., Tsai, D. E., Abada, P., Cheah, C. Y. AMER SOC HEMATOLOGY. 2023
  • Cladribine and Low-Dose Cytarabine-Based Salvage Therapy for Relapsed/Refractory AML in a Predominantly Venetoclax-Exposed Cohort Cheung, E., Schumann, C., Zhang, T. Y., Fakhri, B., Gotlib, J., Liedtke, M., Shomali, W., Mannis, G. AMER SOC HEMATOLOGY. 2023
  • Pirtobrutinib, a Highly Selective, Non-Covalent (Reversible) BTK Inhibitor in Relapsed / Refractory Marginal Zone Lymphoma: Results from Phase 1/2 BRUIN Study Patel, K., Vose, J. M., Nasta, S. D., Brown, J. R., Maddocks, K. J., Woyach, J. A., Shah, N. N., Fakhri, B., Tessoulin, B., Ma, S., Jagadeesh, D., Lech-Maranda, E., Coombs, C. C., Patel, M., Rhodes, J. M., Ujjani, C. S., Hoffmann, M. S., Cheah, C. Y., Munir, T., Lewis, D., Scarfo, L., Eyre, T. A., Alencar, A. J., Cohen, J. B., Zelenetz, A. D., Tsai, D. E., Li, M., Bian, F., Abada, P., Zinzani, P. AMER SOC HEMATOLOGY. 2023
  • Pirtobrutinib in Relapsed/Refractory (R/R) Mantle Cell Lymphoma (MCL) Patients with Prior cBTKi: Safety and Efficacy Including High-Risk Subgroup Analyses from the Phase 1/2 BRUIN Study Cohen, J. B., Shah, N. N., Jurczak, W., Zinzani, P., Cheah, C. Y., Eyre, T. A., Ujjani, C. S., Koh, Y., Kim, W., Nasta, S. D., Flinn, I. W., Tessoulin, B., Ma, S., Alencar, A. J., Lewis, D., Woyach, J. A., Maddocks, K. J., Patel, K., Wang, Y., Rhodes, J. M., Tam, C. S., Seymour, J. F., Nagai, H., Vose, J. M., Fakhri, B., Hoffmann, M. S., Hernandez-Ilizaliturri, F. J., Zelenetz, A. D., Kumar, A., Munir, T., Tsai, D. E., Balbas, M., Liu, B., Ruppert, A. S., Nguyen, B., Roeker, L. E., Wang, M. L. AMER SOC HEMATOLOGY. 2023
  • Pirtobrutinib after a Covalent BTK Inhibitor in Chronic Lymphocytic Leukemia. The New England journal of medicine Mato, A. R., Woyach, J. A., Brown, J. R., Ghia, P., Patel, K., Eyre, T. A., Munir, T., Lech-Maranda, E., Lamanna, N., Tam, C. S., Shah, N. N., Coombs, C. C., Ujjani, C. S., Fakhri, B., Cheah, C. Y., Patel, M. R., Alencar, A. J., Cohen, J. B., Gerson, J. N., Flinn, I. W., Ma, S., Jagadeesh, D., Rhodes, J. M., Hernandez-Ilizaliturri, F., Zinzani, P. L., Seymour, J. F., Balbas, M., Nair, B., Abada, P., Wang, C., Ruppert, A. S., Wang, D., Tsai, D. E., Wierda, W. G., Jurczak, W. 2023; 389 (1): 33-44

    Abstract

    Patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) have poor outcomes after the failure of covalent Bruton's tyrosine kinase (BTK) inhibitor treatment, and new therapeutic options are needed. Pirtobrutinib, a highly selective, noncovalent (reversible) BTK inhibitor, was designed to reestablish BTK inhibition.We conducted a phase 1-2 trial in which patients with relapsed or refractory B-cell cancers received pirtobrutinib. Here, we report efficacy results among patients with CLL or SLL who had previously received a BTK inhibitor as well as safety results among all the patients with CLL or SLL. The primary end point was an overall response (partial response or better) as assessed by independent review. Secondary end points included progression-free survival and safety.A total of 317 patients with CLL or SLL received pirtobrutinib, including 247 who had previously received a BTK inhibitor. Among these 247 patients, the median number of previous lines of therapy was 3 (range, 1 to 11), and 100 patients (40.5%) had also received a B-cell lymphoma 2 (BCL2) inhibitor such as venetoclax. The percentage of patients with an overall response to pirtobrutinib was 73.3% (95% confidence interval [CI], 67.3 to 78.7), and the percentage was 82.2% (95% CI, 76.8 to 86.7) when partial response with lymphocytosis was included. The median progression-free survival was 19.6 months (95% CI, 16.9 to 22.1). Among all 317 patients with CLL or SLL who received pirtobrutinib, the most common adverse events were infections (in 71.0%), bleeding (in 42.6%), and neutropenia (in 32.5%). At a median duration of treatment of 16.5 months (range, 0.2 to 39.9), some adverse events that are typically associated with BTK inhibitors occurred relatively infrequently, including hypertension (in 14.2% of patients), atrial fibrillation or flutter (in 3.8%), and major hemorrhage (in 2.2%). Only 9 of 317 patients (2.8%) discontinued pirtobrutinib owing to a treatment-related adverse event.In this trial, pirtobrutinib showed efficacy in patients with heavily pretreated CLL or SLL who had received a covalent BTK inhibitor. The most common adverse events were infections, bleeding, and neutropenia. (Funded by Loxo Oncology; BRUIN ClinicalTrials.gov number, NCT03740529.).

    View details for DOI 10.1056/NEJMoa2300696

    View details for PubMedID 37407001

  • Hypoxia-specific imaging in patients with lymphoma undergoing CAR-T therapy. European journal of nuclear medicine and molecular imaging Banerjee, R., Wang, V., Huang, C. Y., Pandita, D., Leonard, M. K., LaRue, S., Ahmadi, M., Kaplan, L., Ai, W. Z., Fakhri, B., Spinner, M., Seshadri, M. R., Pampaloni, M. H., Andreadis, C. B. 2023

    Abstract

    Intratumoral hypoxia in non-Hodgkin's Lymphoma (NHL) may interfere with chimeric antigen receptor T-cell (CAR-T) function. We conducted a single-center pilot study (clinicaltrials.gov ID NCT04409314) of [18F]fluoroazomycin arabinoside, a hypoxia-specific radiotracer abbreviated as [18F]FAZA, to assess the feasibility of this positron emission tomography (PET) imaging modality in this population.Patients with relapsed NHL being evaluated for CAR-T therapy received a one-time [18F]FAZA PET scan before pre-CAR-T lymphodepletion. A tumor to mediastinum (T/M) ratio of 1.2 or higher with regard to [18F]FAZA uptake was defined as positive for intratumoral hypoxia. We planned to enroll 30 patients with an interim futility analysis after 16 scans.Of 16 scanned patients, 3 had no evidence of disease by standard [18F]fluorodeoxyglucose PET imaging before CAR-T therapy. Six patients (38%) had any [18F]FAZA uptake above background. Using a T/M cutoff of 1.20, only one patient (a 68-year-old male with relapsed diffuse large B-cell lymphoma) demonstrated intratumoral hypoxia in an extranodal chest wall lesion (T/M 1.35). Interestingly, of all 16 scanned patients, he was the only patient with progressive disease within 1 month of CAR-T therapy. However, because of our low overall proportion of positive scans, our study was stopped for futility.Our pilot study identified low-level [18F]FAZA uptake in a small number of patients with NHL receiving CAR-T therapy. The only patient who met our pre-specified threshold for intratumoral hypoxia was also the only patient with early CAR-T failure. Future plans include exploration of [18F]FAZA in a more selected patient population.

    View details for DOI 10.1007/s00259-023-06296-z

    View details for PubMedID 37300573

    View details for PubMedCentralID 5882485

  • Lisocabtagene maraleucel in chronic lymphocytic leukaemia and small lymphocytic lymphoma (TRANSCEND CLL 004): a multicentre, open-label, single-arm, phase 1-2 study. Lancet (London, England) Siddiqi, T., Maloney, D. G., Kenderian, S. S., Brander, D. M., Dorritie, K., Soumerai, J., Riedell, P. A., Shah, N. N., Nath, R., Fakhri, B., Stephens, D. M., Ma, S., Feldman, T., Solomon, S. R., Schuster, S. J., Perna, S. K., Tuazon, S. A., Ou, S. S., Papp, E., Peiser, L., Chen, Y., Wierda, W. G. 2023

    Abstract

    Patients with relapsed or refractory chronic lymphocytic leukaemia or small lymphocytic lymphoma for whom treatment has failed with both Bruton tyrosine kinase (BTK) inhibitor and venetoclax have few treatment options and poor outcomes. We aimed to evaluate the efficacy and safety of lisocabtagene maraleucel (liso-cel) at the recommended phase 2 dose in patients with relapsed or refractory chronic lymphocytic leukaemia or small lymphocytic lymphoma.We report the primary analysis of TRANSCEND CLL 004, an open-label, single-arm, phase 1-2 study conducted in the USA. Patients aged 18 years or older with relapsed or refractory chronic lymphocytic leukaemia or small lymphocytic lymphoma and at least two previous lines of therapy, including a BTK inhibitor, received an intravenous infusion of liso-cel at one of two target dose levels: 50 × 106 (dose level 1) or 100 × 106 (dose level 2, DL2) chimeric antigen receptor-positive T cells. The primary endpoint was complete response or remission (including with incomplete marrow recovery), assessed by independent review according to the 2018 International Workshop on Chronic Lymphocytic Leukemia criteria, in efficacy-evaluable patients with previous BTK inhibitor progression and venetoclax failure (the primary efficacy analysis set) at DL2 (null hypothesis of ≤5%). This trial is registered with ClinicalTrials.gov, NCT03331198.Between Jan 2, 2018, and June 16, 2022, 137 enrolled patients underwent leukapheresis at 27 sites in the USA. 117 patients received liso-cel (median age 65 years [IQR 59-70]; 37 [32%] female and 80 [68%] male; 99 [85%] White, five [4%] Black or African American, two [2%] other races, and 11 [9%] unknown race; median of five previous lines of therapy [IQR 3-7]); all 117 participants had received and had treatment failure on a previous BTK inhibitor. A subset of patients had also experienced venetoclax failure (n=70). In the primary efficacy analysis set at DL2 (n=49), the rate of complete response or remission (including with incomplete marrow recovery) was statistically significant at 18% (n=9; 95% CI 9-32; p=0·0006). In patients treated with liso-cel, grade 3 cytokine release syndrome was reported in ten (9%) of 117 (with no grade 4 or 5 events) and grade 3 neurological events were reported in 21 (18%; one [1%] grade 4, no grade 5 events). Among 51 deaths on the study, 43 occurred after liso-cel infusion, of which five were due to treatment-emergent adverse events (within 90 days of liso-cel infusion). One death was related to liso-cel (macrophage activation syndrome-haemophagocytic lymphohistiocytosis).A single infusion of liso-cel was shown to induce complete response or remission (including with incomplete marrow recovery) in patients with relapsed or refractory chronic lymphocytic leukaemia or small lymphocytic lymphoma, including patients who had experienced disease progression on a previous BTK inhibitor and venetoclax failure. The safety profile was manageable.Juno Therapeutics, a Bristol-Myers Squibb Company.

    View details for DOI 10.1016/S0140-6736(23)01052-8

    View details for PubMedID 37295445

  • Value of embedded palliative care: outpatient palliative care and healthcare utilization for hematologic malignancies. Blood advances Tsang, M., Bischoff, K. E., Schoenbeck, K. L., Berry, K., O'Riordan, D., Fakhri, B., Wong, S. W., Shah, N., Olin, R. L., Andreadis, C., Vieaux, J., Cohen, E., Shepard Lopez, N., Mannis, G. N., Rabow, M. 2023

    View details for DOI 10.1182/bloodadvances.2022009039

    View details for PubMedID 36809787

  • SOHO State of the Art Updates and Next Questions: New Targetable Pathways in Chronic Lymphocytic Leukemia. Clinical lymphoma, myeloma & leukemia Fakhri, B., Danilov, A. 2023

    Abstract

    Regulatory approvals of Bruton tyrosine kinase (BTK) inhibitors and BCL2 inhibitors have transformed the therapeutic paradigm in chronic lymphocytic leukemia (CLL). However, despite significant improvement, treatment discontinuations due to an acquired resistance mutation or intolerance to these agents are common. Those who are refractory and/or intolerant to both these classes of drugs - the "double exposed/refractory" patients - pose a real challenge in clinical practice and are in dire need of novel therapeutic approaches. In this manuscript, we review the ongoing efforts addressing this unmet clinical need including the ongoing development of non-covalent BTK inhibitors, BTK degraders, novel BH3-mimetics, therapeutic antibodies targeting novel antigens and immune cell enabling therapies.

    View details for DOI 10.1016/j.clml.2023.01.009

    View details for PubMedID 36754692

  • Copy Number Loss at Chromosome 14q11.2 Correlates With the Proportion of T Cells in Biopsies and Helps Identify T-Cell Neoplasms. Archives of pathology & laboratory medicine Saglam, A., Singh, K., Kumar, J., Gollapudi, S., Mukherjee, S., Singh, A., Butzmann, A., Kaplan, L., Andreadis, C., Ai, W. Z., Fakhri, B., Rajkovic, A., Wen, K. W., Onodera, C., Van Ziffle, J., Devine, P. W., Ohgami, R. S. 2022

    Abstract

    Evidence of T-cell clonality is often critical in supporting a T-cell lymphoma.To retrospectively explore the significance of copy number losses at the 14q11.2 T-cell receptor α locus in relation to the presence of a T-cell neoplasm and proportion of T cells by targeted next-generation sequencing.Targeted next-generation sequencing data from 139 tissue biopsies including T-cell lymphomas, B-cell lymphomas, classic Hodgkin lymphomas, nonhematopoietic malignancies, and normal samples were reviewed for copy number losses involving the T-cell receptor α gene segments at chr14q11.2.We found that biallelic or homozygous deletion of 14q11.2 was found in most (28 of 33, 84.8%) T-cell lymphomas. The magnitude of 14q11.2 loss showed a statistically significant correlation with the proportion of T cells in lymphoma tissue samples. Copy number losses could also be detected in other lymphomas with high number of T cells (8 of 32, 25% of B-cell lymphomas, 4 of 4 classical Hodgkin lymphomas), though biallelic/homozygous deletion of 14q11.2 was not significantly observed outside of T-cell lymphomas. Most nonhematopoietic neoplasms and normal tissues (59 of 64, 92.2%) showed no significant copy number losses involving the T-cell receptor α locus at chr14q11.2.Analysis of copy number losses at the T-cell receptor α locus chr14q11.2 with targeted next-generation sequencing can potentially be used to estimate the proportion of T cells and detect T-cell neoplasms.

    View details for DOI 10.5858/arpa.2022-0193-OA

    View details for PubMedID 36445717

  • Outcomes of Therapies and Resistance Mutations Following Non-Covalent Bruton's Tyrosine Kinase Inhibitor Treatment for Patients with Chronic Lymphocytic Leukemia and Richter Transformation Thompson, M. C., Coombs, C. C., Roeker, L. E., Jensen, J. L., Shah, N. N., Luo, T., Patel, K., Bailey, N., Fakhri, B., Eyre, T. A., Ghione, P., Rhodes, J. M., Zelenetz, A. D., Taylor, J., Palomba, M., Meyer, K., Rao, D., Fox, Y., Aronson, J. H., Court, S., Abdel-Wahab, O., Mato, A. R. AMER SOC HEMATOLOGY. 2022: 9885-9888
  • MCL-133 Pirtobrutinib, a Highly Selective, Non-Covalent (Reversible) BTK Inhibitor in Previously Treated Mantle Cell Lymphoma: Updated Results From the Phase 1/2 BRUIN Study. Clinical lymphoma, myeloma & leukemia Cohen, J. B., Shah, N. N., Alencar, A. J., Gerson, J. N., Patel, M. R., Fakhri, B., Jurczak, W., Tan, X. N., Lewis, K. L., Fenske, T., Coombs, C. C., Flinn, I. W., Lewis, D. J., Gouill, S. L., Palomba, M. L., Woyach, J. A., Pagel, J. M., Lamanna, N., Barve, M. A., Ghia, P., Eyre, T. A., Zinzani, P. L., Ujjani, C. S., Koh, Y., Izutsu, K., Lech-Maranda, E., Tam, C. S., Sundaram, S., Yin, M., Nair, B., Tsai, D. E., Balbas, M., Mato, A. R., Cheah, C. Y., Wang, M. L. 2022; 22 Suppl 2: S394-S395

    Abstract

    Covalent BTK inhibitors (BTKi) have transformed the management of mantle cell lymphoma (MCL), but most patients will require additional treatment. Pirtobrutinib is a highly selective, non-covalent (reversible) BTKi that inhibits both wild-type and C481-mutated BTK with equal low nM potency.To evaluate pirtobrutinib safety and efficacy in patients with MCL.BRUIN is an ongoing multicenter phase 1/2 study (NCT03740529) of pirtobrutinib monotherapy.Global; community hospitals, academic medical centers.Patients with advanced B-cell malignancies.Oral pirtobrutinib, phase 1 dose-escalated in a standard 3+3 design, phase 2 continuous therapy, 28-day cycles.The primary phase 1 objective was to determine the recommended phase 2 dose (RP2D) and the primary phase 2 objective was overall response rate (ORR); secondary objectives included duration of response, progression-free survival, overall survival, safety/tolerability, and pharmacokinetics.As of 27 September 2020, 323 patients (170 CLL/SLL, 61 MCL, 26 WM, 26 DLBCL, 13 MZL, 12 FL, 9 RT, and 6 other NHL) were treated on 7 dose levels (25-300mg QD). No DLTs were reported and MTD was not reached (n=323). 200mg QD was selected as the RP2D. Fatigue (20%), diarrhea (17%) and contusion (13%) were the most frequent treatment-emergent adverse events regardless of attribution or grade seen in >10% of patients. The most common adverse event of grade ≥3 was neutropenia (10%). Five (1%) patients discontinued due to treatment-related adverse events. 52 prior BTKi treated MCL patients were efficacy evaluable with an ORR of 52% (95% CI 38-66; 13 CR [25%], 14 PR [27%], 9 SD [17%]), 11 PD [21%] and 5 [10%] discontinued prior to first response assessment). Median follow-up was 6 months (0.7-18.3+). Responses were observed in 9/14 patients (64%) with prior autologous or allogeneic stem cell transplant, and 2/2 with prior CAR-T cell therapy.Pirtobrutinib demonstrated promising efficacy in heavily pretreated, poor-prognosis MCL following multiple prior lines of therapy, including a covalent BTKi. Pirtobrutinib was well tolerated and exhibited a wide therapeutic index. Updated data, including approximately 60 new patients with MCL and an additional 10 months since the prior data-cut will be presented.

    View details for DOI 10.1016/S2152-2650(22)01569-5

    View details for PubMedID 36164120

  • CLL-120 Pirtobrutinib, A Highly Selective, Non-Covalent (Reversible) BTK Inhibitor in Previously Treated CLL/SLL: Updated Results from the Phase 1/2 BRUIN Study. Clinical lymphoma, myeloma & leukemia Coombs, C. C., Pagel, J. M., Shah, N. N., Lamanna, N., Munir, T., Lech-Maranda, E., Eyre, T. A., Woyach, J. A., Wierda, W. G., Cheah, C. Y., Cohen, J. B., Roeker, L. E., Patel, M. R., Fakhri, B., Barve, M. A., Tam, C. S., Lewis, D., Gerson, J. N., Alencar, A., Ujjani, C., Flinn, I., Sundaram, S., Ma, S., Jagadeesh, D., Rhodes, J., Taylor, J., Abdel-Wahab, O., Ghia, P., Schuster, S. J., Wang, D., Nair, B., Zhu, E., Tsai, D. E., Davids, M. S., Brown, J. R., Jurczak, W., Mato, A. R. 2022; 22 Suppl 2: S268-S269

    Abstract

    Covalent BTK inhibitors (BTKi) have transformed the management of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), but many patients (pts) will require additional treatment. Pirtobrutinib is a highly selective, non-covalent (reversible) BTKi that inhibits both wild type and C481-mutated BTK with equal low nM potency.To evaluate the safety and efficacy of pirtobrutinib in previously treated CLL/SLL.BRUIN is a phase 1/2 multicenter study (NCT03740529) of oral pirtobrutinib monotherapy.Global; community hospitals, academic medical centers.Pts with advanced B-cell malignancies.Oral pirtobrutinib, phase 1 dose escalated in a standard 3+3 design, phase 2 continuous monotherapy, 28-day cycles.The primary objective for phase 1 was to determine the recommended phase 2 dose (RP2D). The primary objective of phase 2 was ORR. Secondary objectives included duration of response, progression-free survival, overall survival, safety and tolerability, and pharmacokinetics.As of 27 September 2020, 323 previously treated pts with B-cell malignancies (170 CLL/SLL, 61 MCL, 26 WM, and 66 other) were treated on 7 dose levels (25-300mg QD). No dose limiting toxicities were reported and MTD was not reached (n=323). 200mg QD was selected as RP2D. Fatigue (20%), diarrhea (17%) and contusion (13%) were the most frequent TEAEs regardless of attribution or grade seen in >10% pts. Most common AE of grade ≥3 was neutropenia (10%). 139 CLL/SLL pts were efficacy-evaluable with a median follow up time of 6 months (0.16-17.8+). ORR was 63% (95%CI 55-71) with 69 PRs (50%), 19 PR-Ls (14%), 45 SDs (32%) and 1 PD (1%), and 5 (4%) discontinued prior to first response assessment. Among 121 BTKi pretreated pts, ORR was 62% (95%CI 53-71). Responses deepened over time with an ORR of 86% among pts with >10 months follow-up. ORR was similar in pts who discontinued prior BTKi due to progression (67%), or adverse events or other (52%). Of 88 responding pts, all except 5 remained on therapy.Pirtobrutinib demonstrated promising efficacy in heavily pretreated CLL/SLL pts. Pirtobrutinib was well tolerated and exhibited a wide therapeutic index. Updated data from 252 efficacy evaluable BTK pre-treated CLL/SLL patients with a data cutoff date of 16 July 2021 will be presented.

    View details for DOI 10.1016/S2152-2650(22)01327-1

    View details for PubMedID 36163872

  • Evaluation of pulmonary toxicities in lymphoma patients receiving brentuximab vedotin. Leukemia & lymphoma Guan, T., Lo, M., Young, R., Ai, W., Boulbol, F., Mouanoutoua, H., Chu, R., Andreadis, C., Kaplan, L., Abdulhaq, H., Fakhri, B. 2022: 1-4

    View details for DOI 10.1080/10428194.2022.2100369

    View details for PubMedID 35875857

  • Embedded outpatient palliative care for hematologic malignancies: Referral patterns and health care utilization. Tsang, M., Bischoff, K. E., Schoenbeck, K. L., Berry, K., O'Riordan, D., Fakhri, B., Wong, S., Shah, N., Cohen, E., Lopez, N., Mannis, G. N., Rabow, M. W. LIPPINCOTT WILLIAMS & WILKINS. 2022
  • Toci or not toci: innovations in the diagnosis, prevention, and early management of cytokine release syndrome. Leukemia & lymphoma Banerjee, R., Fakhri, B., Shah, N. 2021; 62 (11): 2600-2611

    Abstract

    Cytokine release syndrome (CRS) remains a significant toxicity of chimeric antigen receptor T-cell (CAR-T) therapy for hematologic malignancies. While established guidelines exist for the management of Grade 2+ CRS with immunosuppressive agents such as tocilizumab or corticosteroids, the management of early-grade CRS (i.e. Grade 1 CRS with isolated fevers) has no such consensus beyond supportive care. In this review, we discuss early-grade CRS with an emphasis on its diagnosis, management, and prevention. Strategies to target early-grade CRS include immunosuppression preemptively (once CRS develops) or prophylactically (before CRS develops) as well as novel small-molecule inhibitors or fractionated CAR-T dosing. In the near future, next-generation CAR-T therapies may be able to target CRS precisely or obviate CRS entirely. If shown to prevent CRS-associated morbidity while maintaining therapeutic anti-neoplastic efficacy, these innovative strategies will enhance the safety of CAR-T therapy while also improving its operationalization and accessibility in the real-world setting.

    View details for DOI 10.1080/10428194.2021.1924370

    View details for PubMedID 34151714

  • Current and emerging treatment options in primary mediastinal B-cell lymphoma. Therapeutic advances in hematology Fakhri, B., Ai, W. 2021; 12: 20406207211048959

    Abstract

    Previously considered a subtype of diffuse large B-cell lymphoma (DLBCL), primary mediastinal B-cell lymphoma (PMBCL) is now recognized by the World Health Organization as an independent entity. PMBCL has clinicopathologic features that are separate from systemic DLBCL and harbors some biologic characteristics which overlap with nodular sclerosing classic Hodgkin's lymphoma (cHL). Similar to cHL, copy number alterations of 9p24.1 are frequently seen in PMBCL, which leads to increased expression of key genes in the region, including programmed death-ligand 1( PD-L1), PD-L2, and JAK2. In addition, PMBCL cells express CD30 in a mostly patchy fashion. In the upfront setting, dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (i.e., DA-EPOCH-R) is the only regimen that has been shown in a prospective setting to result in outstanding outcomes without consolidative radiation to the mediastinum, with a 5-year event-free survival rate of 93% and overall survival rate of 97%. Thus, in recent years, DA-EPOCH-R has been recognized as the preferred frontline regimen. Despite the encouraging results in the frontline setting, the outcomes in the relapsed/refractory setting remain poor. The current approach of salvage chemotherapy followed by autologous stem cell transplantation, as used in patients with DLBCL, does not result in high rates of cure in patients with rrPMBCL. In recent years, the characteristic molecular features identified in PMBCL have provided more treatment opportunities for this patient population. In the relapsed setting, single-agent PD-1 inhibitor pembrolizumab have demonstrated high and durable remission rates. Despite the expression of CD30, the CD30 antibody drug-conjugate brentuximab vedotin (BV) as a single agent has been deemed inactive in this disease. On the contrary, the combinations of BV and PD-1 inhibitor have shown higher response rates than PD-1 inhibitor alone. Moreover, anti-CD19 chimeric antigen receptor T-cell (CAR T-cell) therapy has been positioned as another successful strategy for patients with rrPMBCL. Axicabtagene ciloleucel and lisocabtagene maraleucel are two products used in rrPMBCL.

    View details for DOI 10.1177/20406207211048959

    View details for PubMedID 34659697

    View details for PubMedCentralID PMC8511915

  • Survival after autologous versus allogeneic transplantation in patients with relapsed and refractory Hodgkin lymphoma. Leukemia & lymphoma Fakhri, B., Yilmaz, E., Gao, F., Ambinder, R. F., Jones, R., Bartlett, N. L., Cashen, A., Wagner-Johnston, N. 2021; 62 (10): 2408-2415

    Abstract

    For relapsed Hodgkin lymphoma, salvage chemotherapy followed by auto-HCT is the standard of care. It is important to identify subpopulations who could benefit from allo-HCT. This retrospective analysis included 277 patients with rrHL who underwent first transplant with auto-HCT or allo-HCT between 2007-2017. Patients in the auto-HCT cohort (N = 218) were older, more likely to be in CR at the time of transplant and receive maintenance therapy post-transplant. Patients who underwent allo-HCT (N = 59) had a higher MSKCC relapse score. Factors associated with an inferior PFS and OS included early relapse, advanced stage, extranodal involvement and not achieving CR following salvage chemotherapy. After controlling for these 4 risk factors and MSKCC score, PFS (p = 0.112) or OS (p = 0.256) was not affected by the choice of transplant. In patients with ≥ 3 high risk features, the 4-year PFS was 51% in the allo-HCT vs. 39% (p = 0.107) in the auto-HCT cohort.

    View details for DOI 10.1080/10428194.2021.1927016

    View details for PubMedID 33988071

  • Incidence, management and outcomes of arterial and venous thrombosis after chimeric antigen receptor modified T cells for B cell lymphoma and multiple myeloma. Leukemia & lymphoma Parks, A. L., Kambhampati, S., Fakhri, B., Andreadis, C., Gray, L., Wong, S. W., Shah, N., Fang, M. C. 2021; 62 (4): 1003-1006

    View details for DOI 10.1080/10428194.2020.1852474

    View details for PubMedID 33258699

    View details for PubMedCentralID PMC8012226

  • Ofatumumab, Etoposide, and Cytarabine Intensive Mobilization Regimen in Patients with High-risk Relapsed/Refractory Diffuse Large B-Cell Lymphoma Undergoing Autologous Stem Cell Transplantation. Clinical lymphoma, myeloma & leukemia Kambhampati, S., Hunter, B., Varnavski, A., Fakhri, B., Kaplan, L., Ai, W. Z., Pampaloni, M., Huang, C. Y., Martin, T., Damon, L., Andreadis, C. B. 2021; 21 (4): 246-256.e2

    Abstract

    More than one-half of high-risk patients with relapsed/refractory (rr) diffuse large B-cell lymphoma (DLBCL) relapse after autologous hematopoietic cell transplantation (auto-HCT). In this phase II study, we investigate the long-term outcomes of high-risk patients with rrDLBCL receiving intensive consolidation therapy (ICT) with OVA (ofatumumab, etoposide, and high-dose cytarabine) prior to auto-HCT.The primary endpoints were the ability of OVA to mobilize peripheral stem cells and the 2-year progression-free survival (PFS) rate following OVA. Secondary endpoints included safety, 2-year overall survival (OS), impact of cell of origin (COO), and the prognostic utility of next-generation sequencing minimal residual disease (MRD) testing. We simultaneously retrospectively assessed the outcomes of DLBCL patients who underwent ICT with a similar regimen at our institution.Twenty-seven patients received salvage chemotherapy, with a response rate of 25% in patients with germinal center B-cell (GCB)-DLBCL versus 92% in patients with non-GCB-DLBCL (P = .003). Nineteen responding patients underwent ICT with OVA (100% successful stem cell mobilization). The 2-year PFS and OS rate was 47% and 59%, respectively, with no difference based on COO. Similar findings were observed when the study and retrospective cohorts were combined. Neutropenia was the most common toxicity (47%). MRD-negative patients at the completion of salvage had a median OS of not reached versus 3.5 months in MRD-positive patients (P = .02).OVA followed by auto-HCT is effective and safe for high-risk rrDLBCL. Patients with GCB-DLBCL had a lower response to salvage chemotherapy, but no difference in outcomes based on COO was seen after auto-HCT. MRD testing in the relapsed setting was predictive of long-term survival.

    View details for DOI 10.1016/j.clml.2020.11.005

    View details for PubMedID 33288485

  • Pirtobrutinib in relapsed or refractory B-cell malignancies (BRUIN): a phase 1/2 study. Lancet (London, England) Mato, A. R., Shah, N. N., Jurczak, W., Cheah, C. Y., Pagel, J. M., Woyach, J. A., Fakhri, B., Eyre, T. A., Lamanna, N., Patel, M. R., Alencar, A., Lech-Maranda, E., Wierda, W. G., Coombs, C. C., Gerson, J. N., Ghia, P., Le Gouill, S., Lewis, D. J., Sundaram, S., Cohen, J. B., Flinn, I. W., Tam, C. S., Barve, M. A., Kuss, B., Taylor, J., Abdel-Wahab, O., Schuster, S. J., Palomba, M. L., Lewis, K. L., Roeker, L. E., Davids, M. S., Tan, X. N., Fenske, T. S., Wallin, J., Tsai, D. E., Ku, N. C., Zhu, E., Chen, J., Yin, M., Nair, B., Ebata, K., Marella, N., Brown, J. R., Wang, M. 2021; 397 (10277): 892-901

    Abstract

    Covalent Bruton's tyrosine kinase (BTK) inhibitors are efficacious in multiple B-cell malignancies, but patients discontinue these agents due to resistance and intolerance. We evaluated the safety and efficacy of pirtobrutinib (working name; formerly known as LOXO-305), a highly selective, reversible BTK inhibitor, in these patients.Patients with previously treated B-cell malignancies were enrolled in a first-in-human, multicentre, open-label, phase 1/2 trial of the BTK inhibitor pirtobrutinib. The primary endpoint was the maximum tolerated dose (phase 1) and overall response rate (ORR; phase 2). This trial is registered with ClinicalTrials.gov, NCT03740529.323 patients were treated with pirtobrutinib across seven dose levels (25 mg, 50 mg, 100 mg, 150 mg, 200 mg, 250 mg, and 300 mg once per day) with linear dose-proportional exposures. No dose-limiting toxicities were observed and the maximum tolerated dose was not reached. The recommended phase 2 dose was 200 mg daily. Adverse events in at least 10% of 323 patients were fatigue (65 [20%]), diarrhoea (55 [17%]), and contusion (42 [13%]). The most common adverse event of grade 3 or higher was neutropenia (32 [10%]). There was no correlation between pirtobrutinib exposure and the frequency of grade 3 treatment-related adverse events. Grade 3 atrial fibrillation or flutter was not observed, and grade 3 haemorrhage was observed in one patient in the setting of mechanical trauma. Five (1%) patients discontinued treatment due to a treatment-related adverse event. In 121 efficacy evaluable patients with chronic lymphocytic leukaemia (CLL) or small lymphocytic lymphoma (SLL) treated with a previous covalent BTK inhibitor (median previous lines of treatment 4), the ORR with pirtobrutinib was 62% (95% CI 53-71). The ORR was similar in CLL patients with previous covalent BTK inhibitor resistance (53 [67%] of 79), covalent BTK inhibitor intolerance (22 [52%] of 42), BTK C481-mutant (17 [71%] of 24) and BTK wild-type (43 [66%] of 65) disease. In 52 efficacy evaluable patients with mantle cell lymphoma (MCL) previously treated with covalent BTK inhibitors, the ORR was 52% (95% CI 38-66). Of 117 patients with CLL, SLL, or MCL who responded, all but eight remain progression-free to date.Pirtobrutinib was safe and active in multiple B-cell malignancies, including patients previously treated with covalent BTK inhibitors. Pirtobrutinib might address a growing unmet need for alternative therapies for these patients.Loxo Oncology.

    View details for DOI 10.1016/S0140-6736(21)00224-5

    View details for PubMedID 33676628

  • Carfilzomib in Combination With Bendamustine and Rituximab in Patients With Relapsed or Refractory Non-Hodgkin Lymphoma: A Phase I Trial. Clinical lymphoma, myeloma & leukemia Kambhampati, S., Fakhri, B., Ai, W. Z., Kaplan, L. D., Tuscano, J. M., Wieduwilt, M. J., Sudhindra, A., Cavallone, E., Reiner, J., Aoun, C., Castillo, M., Martinelli, M., Ta, T., Le, D., Padilla, M., Crawford, E., Andreadis, C. B. 2021; 21 (3): 139-146

    Abstract

    We designed a multicenter, phase Ib dose-escalation trial of carfilzomib with bendamustine and rituximab in patients with relapsed/refractory non-Hodgkin lymphoma (NCT02187133) in order to improve the response rates of this difficult-to-treat population. Chemoimmunotherapy with bendamustine and rituximab has shown activity in a variety of lymphomas, and proteasome inhibitors have demonstrated pre-clinical synergy and early clinical activity in this population. The objectives were to determine the maximum tolerated dose of carfilzomib and the preliminary efficacy of this combination.The protocol followed a 3+3 design of carfilzomib dose escalation combined with standard doses of bendamustine and rituximab. Patients were treated for up to 6 cycles with an interim positron emission tomography/computed tomography after cycle 3.Ten patients were treated on the dose-escalation phase. The study was terminated at a carfilzomib dose of 56 mg/m2, and the maximum tolerated dose was not reached. The most common grade 3/4 adverse event was thrombocytopenia. There was 1 dose-limiting toxicity observed, grade 3 febrile neutropenia, and there were no treatment-related deaths. The overall response rate was 40% (complete response rate, 30%), with a median duration of response of 12 months and a median progression-free survival of 2.1 months.Carfilzomib in combination with bendamustine and rituximab is a safe and well-tolerated treatment for patients with relapsed/refractory non-Hodgkin lymphoma. Preliminary data indicate that this combination may have efficacy with an acceptable side effect profile in this heavily pre-treated patient population with limited treatment options.

    View details for DOI 10.1016/j.clml.2020.12.020

    View details for PubMedID 33478921

  • A Case of EBV-Negative Aggressive NK-cell Leukemia: Use of Next-Generation Sequencing in Demystifying a Diagnostic Dilemma and Guiding Clinical Care. Clinical lymphoma, myeloma & leukemia Kennedy, V. E., Ruiz-Cordero, R., Jangam, D., Wen, K. W., Dunavin, N., Ohgami, R. S., Bhargava, P., Ai, W., Fakhri, B. 2021

    View details for DOI 10.1016/j.clml.2021.02.010

    View details for PubMedID 33814335

  • The role of acalabrutinib in adults with chronic lymphocytic leukemia. Therapeutic advances in hematology Fakhri, B., Andreadis, C. 2021; 12: 2040620721990553

    Abstract

    The treatment landscape of chronic lymphocytic leukemia (CLL) has significantly changed in the past decade. This paradigm shift is due to the introduction of novel agents to the field. The two major classes of drugs that have contributed to this dramatic evolution include the Bruton tyrosine kinase (BTK) inhibitors and BCL2 inhibitors. Ibrutinib was the first-in-class drug which was initially approved by the US Food and Drug Administration (FDA) for the treatment of patients with relapsed/refractory and later for patients with treatment-naïve CLL. Despite encouraging efficacy outcomes, its use has been associated with cardiovascular and gastrointestinal toxicities likely due to off-target inhibition of ITK, TEC and EGFR family kinases. The next generation of BTK inhibitors was developed to be more selective with less off-target inhibition with the prospect to improve tolerability without compromising efficacy. Acalabrutinib, a selective covalent BTK inhibitor, is a second generation BTK inhibitor. The focus of this review is on two major phase III trials that resulted in the FDA approval of acalabrutinib in 2019. The ELEVATE TN trial investigated acalabrutinib with or without obintuzumab versus chlorambucil-obinutuzumab in older and frail patients with previously untreated CLL. The ASCEND trial explored acalabrutinib versus chemoimmunotherapy in patients with relapsed/refractory CLL. Both trials demonstrated superiority of the acalabrutinib-containing arms in terms of both efficacy and tolerability. Unfortunately, the availability of new generation BTK inhibitors has not resulted in mitigating the financial toxicities associated with these potentially life-long treatments.

    View details for DOI 10.1177/2040620721990553

    View details for PubMedID 33613932

    View details for PubMedCentralID PMC7871059

  • NCCN Guidelines Insights: B-Cell Lymphomas, Version 5.2021. Journal of the National Comprehensive Cancer Network : JNCCN Zelenetz, A. D., Gordon, L. I., Chang, J. E., Christian, B., Abramson, J. S., Advani, R. H., Bartlett, N. L., Budde, L. E., Caimi, P. F., De Vos, S., Dholaria, B., Fakhri, B., Fayad, L. E., Glenn, M. J., Habermann, T. M., Hernandez-Ilizaliturri, F., Hsi, E., Hu, B., Kaminski, M. S., Kelsey, C. R., Khan, N., Krivacic, S., LaCasce, A. S., Lim, M., Narkhede, M., Rabinovitch, R., Ramakrishnan, P., Reid, E., Roberts, K. B., Saeed, H., Smith, S. D., Svoboda, J., Swinnen, L. J., Tuscano, J., Vose, J. M., Dwyer, M. A., Sundar, H. 2021; 19 (11): 1218-1230

    Abstract

    In the last decade, a better understanding of the molecular pathogenesis of B-cell non-Hodgkin lymphomas has resulted in the development of novel targeted therapies, such as small molecule inhibitors of select kinases in the B-cell receptor pathway, antibody-drug conjugates, and small molecules that target a variety of proteins (eg, CD-19, EZH2, and XPO-1-mediated nuclear export). Anti-CD19 CAR T-cell therapy, first approved for relapsed/refractory (R/R) diffuse large B-cell lymphoma, has also emerged as a novel treatment option for R/R follicular lymphoma and mantle cell lymphoma. These NCCN Guideline Insights highlight the new targeted therapy options included in the NCCN Guidelines for B-Cell Lymphomas for the treatment of R/R disease.

    View details for DOI 10.6004/jnccn.2021.0054

    View details for PubMedID 34781267

  • Assessment of the Efficacy of Therapies Following Venetoclax Discontinuation in CLL Reveals BTK Inhibition as an Effective Strategy. Clinical cancer research : an official journal of the American Association for Cancer Research Mato, A. R., Roeker, L. E., Jacobs, R., Hill, B. T., Lamanna, N., Brander, D., Shadman, M., Ujjani, C. S., Yazdy, M. S., Perini, G. F., Pinilla-Ibarz, J. A., Barrientos, J., Skarbnik, A. P., Torka, P., Pu, J. J., Pagel, J. M., Gohil, S., Fakhri, B., Choi, M., Coombs, C. C., Rhodes, J., Barr, P. M., Portell, C. A., Parry, H., Garcia, C. A., Whitaker, K. J., Winter, A. M., Sitlinger, A., Khajavian, S., Grajales-Cruz, A. F., Isaac, K. M., Shah, P., Akhtar, O. S., Pocock, R., Lam, K., Voorhees, T. J., Schuster, S. J., Rodgers, T. D., Fox, C. P., Martinez-Calle, N., Munir, T., Bhavsar, E. B., Bailey, N., Lee, J. C., Weissbrot, H. B., Nabhan, C., Goodfriend, J. M., King, A. C., Zelenetz, A. D., Dorsey, C., Bigelow, K., Cheson, B. D., Allan, J. N., Eyre, T. A. 2020; 26 (14): 3589-3596

    Abstract

    Venetoclax-based therapy is a standard-of-care option in first-line and relapsed/refractory chronic lymphocytic leukemia (CLL). Patient management following venetoclax discontinuation remains nonstandard and poorly understood.To address this, we conducted a large international study to identify a cohort of 326 patients who discontinued venetoclax and have been subsequently treated. Coprimary endpoints were overall response rate (ORR) and progression-free survival for the post-venetoclax treatments stratified by treatment type [Bruton's tyrosine kinase inhibitor (BTKi), PI3K inhibitor (PI3Ki), and cellular therapies].We identified patients with CLL who discontinued venetoclax in the first-line (4%) and relapsed/refractory settings (96%). Patients received a median of three therapies prior to venetoclax; 40% were BTKi naïve (n = 130), and 81% were idelalisib naïve (n = 263). ORR to BTKi was 84% (n = 44) in BTKi-naïve patients versus 54% (n = 30) in BTKi-exposed patients. We demonstrate therapy selection following venetoclax requires prior novel agent exposure consideration and discontinuation reasons.For BTKi-naïve patients, selection of covalently binding BTKis results in high ORR and durable remissions. For BTKi-exposed patients, covalent BTK inhibition is not effective in the setting of BTKi resistance. PI3Kis following venetoclax do not appear to result in durable remissions. We conclude that BTKi in naïve or previously responsive patients and cellular therapies following venetoclax may be the most effective strategies.See related commentary by Rogers, p. 3501.

    View details for DOI 10.1158/1078-0432.CCR-19-3815

    View details for PubMedID 32198151

    View details for PubMedCentralID PMC8588795

  • Immune-related Adverse Events Associated With Checkpoint Inhibition in the Setting of CAR T Cell Therapy: A Case Series. Clinical lymphoma, myeloma & leukemia Kambhampati, S., Gray, L., Fakhri, B., Lo, M., Vu, K., Arora, S., Kaplan, L., Ai, W. Z., Andreadis, C. 2020; 20 (3): e118-e123

    View details for DOI 10.1016/j.clml.2019.12.014

    View details for PubMedID 31948859

  • Measuring cardiopulmonary complications of carfilzomib treatment and associated risk factors using the SEER-Medicare database. Cancer Fakhri, B., Fiala, M. A., Shah, N., Vij, R., Wildes, T. M. 2020; 126 (4): 808-813

    Abstract

    Carfilzomib improves survival in patients with recurrent myeloma. Given the strict eligibility criteria in clinical trials, the actual frequency of cardiac adverse events (CAEs) and pulmonary adverse events (PAEs) and the risk factors associated with these AEs in the general population need to be established.The authors extracted myeloma cases in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database from 2000 through 2013 and corresponding claims through 2014. They then identified patients who received carfilzomib during their disease course. Subsequently, the International Classification of Diseases, Ninth Revision (ICD-9) was used to identify all the codes for CAEs, PAEs, and respiratory infections associated with carfilzomib use. Preexisting diagnoses corresponding to the CAEs and PAEs of interest were excluded to distinguish toxicity from comorbidity. Multivariate Cox regression was performed to determine those variables independently associated with the development of CAEs and PAEs.Of the 635 patients analyzed, the median age was 72 years (range, 36-94 years); 55% of the patients were male and 79% were white. The median duration of carfilzomib treatment was 58 days (range, 1-716 days). Overall, approximately 66% of the patients had codes for either CAEs or PAEs. In terms of CAEs, approximately 22% of patients developed hypertension, 15% developed peripheral edema, and 14% experienced heart failure. With regard to PAEs, approximately 28% of patients developed dyspnea, 15% developed cough, and 15% developed pneumonia. Only chronic obstructive pulmonary disease (COPD) was found to be independently associated with the development of CAEs. Patients with preexisting COPD were found to have a 40% increase in their hazard of developing CAEs (adjusted hazard ratio, 1.40; 95% CI, 1.03-1.90).In older adults with myeloma who are undergoing treatment with carfilzomib, new cardiac and pulmonary diagnoses were common. Patients with preexisting COPD were found to be at an increased risk of developing CAEs.

    View details for DOI 10.1002/cncr.32601

    View details for PubMedID 31721140

    View details for PubMedCentralID PMC6992490

  • Outcomes in patients with aggressive B-cell non-Hodgkin lymphoma after intensive frontline treatment failure. Cancer Ayers, E. C., Li, S., Medeiros, L. J., Bond, D. A., Maddocks, K. J., Torka, P., Mier Hicks, A., Curry, M., Wagner-Johnston, N. D., Karmali, R., Behdad, A., Fakhri, B., Kahl, B. S., Churnetski, M. C., Cohen, J. B., Reddy, N. M., Modi, D., Ramchandren, R., Howlett, C., Leslie, L. A., Cytryn, S., Diefenbach, C. S., Faramand, R., Chavez, J. C., Olszewski, A. J., Liu, Y., Barta, S. K., Mukhija, D., Hill, B. T., Ma, H., Amengual, J. E., Nathan, S., Assouline, S. E., Orellana-Noia, V. M., Portell, C. A., Chandar, A., David, K. A., Giri, A., Hess, B. T., Landsburg, D. J. 2020; 126 (2): 293-303

    Abstract

    Salvage immunochemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation is the standard-of-care second-line treatment for patients with relapsed/refractory diffuse large B-cell lymphoma after first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Outcomes after receipt of second-line immunochemotherapy in patients with aggressive B-cell lymphomas who relapse or are refractory to intensive first-line immunochemotherapy regimens (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab [R-EPOCH], rituximab, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with methotrexate and cytarabine [R-HyperCVAD], rituximab, cyclophosphamide, vincristine, doxorubicin, and high-dose methotrexate alternating with ifosfamide, etoposide, and cytarabine [R-CODOX-M/IVAC]) remain unknown.Outcomes of patients with non-Burkitt, aggressive B-cell lymphomas and relapsed/refractory disease after first-line treatment with intensive immunochemotherapy regimens who received platinum-based second-line immunochemotherapy were reviewed retrospectively. Analyses were performed to determine progression-free survival (PFS) and overall survival (OS) from the time of receipt of second-line immunochemotherapy.In total, 195 patients from 19 academic centers were included in the study. The overall response rate to second-line immunochemotherapy was 44%, with a median PFS of 3 months and a median OS of 8 months. Patients with early treatment failure (primary refractory or relapse <12 months from completion of first-line therapy) experienced inferior median PFS (2.8 vs 23 months; P < .001) and OS (6 months vs not reached; P < .001) compared with patients with late treatment failure. Although the 17% of patients with early failure who achieved a complete response to second-line immunochemotherapy experienced prolonged survival, this outcome could not be predicted by clinicopathologic features at the start of second-line immunochemotherapy.Patients with early treatment failure after intensive first-line immunochemotherapy experience poor outcomes after receiving standard second-line immunochemotherapy. The use of standard-of-care or experimental therapies currently available in the third-line setting and beyond should be investigated in the second-line setting for these patients.

    View details for DOI 10.1002/cncr.32526

    View details for PubMedID 31568564

  • Complexities in the diagnosis of large B-cell lymphomas, classic Hodgkin lymphomas and overlapping peripheral T-cell lymphomas simplified: An evidence-based guide. Annals of diagnostic pathology Wen, K. W., Fakhri, B. n., Menke, J. n., Ruiz-Cordero, R. n., Gill, R. M., Ohgami, R. S. 2020; 46: 151534

    Abstract

    The diagnosis of a large B-cell lymphoma and classic Hodgkin lymphoma (CHL) is often straightforward. However, in select circumstances, these simple diagnoses can be quite complex. In part, diagnostic difficulty may be due to uncertainty in the evaluation of morphologic and immunophenotypic features along a biologic continuum, or alternatively arise from uncertainty in predicting the behavior and outcomes of patients. Here, we systematically discuss and review areas of diagnostic difficulty in the diagnosis of large B-cell lymphomas (LBCL), classic Hodgkin lymphomas (CHL) and peripheral T-cell lymphomas (PTCL). We provide careful data-driven analyses and evidence-based approaches to help guide pathologists and clinicians. We discuss: 1) marginal zone lymphomas with increased large cells versus diffuse large B-cell lymphoma (DLBCL), 2) chronic lymphocytic leukemia with expanded proliferation centers versus diffuse large B-cell lymphoma (DLBCL), 3) chronic lymphocytic leukemia with Hodgkin/Reed-Sternberg-like cells versus CHL arising from chronic lymphocytic leukemia, 4) complex cases of follicular lymphoma versus DLBCL, 5) PTCL with large B-cell proliferations versus PTCL with LBCL, 6) PTCL with Hodgkin/Reed-Sternberg-like cells versus CHL, and finally 7) blastoid/pleomorphic mantle cell lymphoma versus DLBCL. Our evidence and data driven approach may serve as a useful diagnostic guide.

    View details for DOI 10.1016/j.anndiagpath.2020.151534

    View details for PubMedID 32473554

  • CLL14 Trial: Fixed-Duration Chemotherapy-Free Regimen for Frail Patients with Treatment-Naïve CLL. Oncology (Williston Park, N.Y.) Fakhri, B., Andreadis, C. 2019; 33 (11)

    View details for PubMedID 31769861

  • Fifty Shades of GATA2 Mutation: A Case of Plasmablastic Lymphoma, Nontuberculous Mycobacterial Infection, and Myelodysplastic Syndrome. Clinical lymphoma, myeloma & leukemia Fakhri, B., Cashen, A. F., Duncavage, E. J., Watkins, M. P., Wartman, L. D., Bartlett, N. L. 2019; 19 (9): e532-e535

    View details for DOI 10.1016/j.clml.2019.05.015

    View details for PubMedID 31279773

  • Maintenance rituximab or observation after frontline treatment with bendamustine-rituximab for follicular lymphoma. British journal of haematology Hill, B. T., Nastoupil, L., Winter, A. M., Becnel, M. R., Cerhan, J. R., Habermann, T. M., Link, B. K., Maurer, M. J., Fakhri, B., Reddy, P., Smith, S. D., Mukhija, D., Jagadeesh, D., Desai, A., Alderuccio, J. P., Lossos, I. S., Mehra, P., Portell, C. A., Goldman, M. L., Calzada, O., Cohen, J. B., Hussain, M. J., Ghosh, N., Caimi, P., Tiutan, T., Martin, P., Kodali, A., Evens, A. M., Kahl, B. S. 2019; 184 (4): 524-535

    Abstract

    Bendamustine (B) with rituximab (R) is a standard frontline treatment for medically fit follicular lymphoma (FL) patients. The safety and efficacy of maintenance rituximab (MR) after BR induction has not been formally compared to observation for FL, resulting in disparate practice patterns. Prospective trials have shown benefit of MR after R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) or R-CVP (rituximab, cyclophosphamide, vincristine, prednisone), yet recent data from the GALLIUM study comparing outcomes of patients treated with chemotherapy with R or obinutuzumab (G) showed higher than anticipated fatal adverse events with BR/BG. In order to assess the efficacy and tolerability of MR after BR, we retrospectively collected data on 640 newly diagnosed patients treated with FL. We found that patients who achieved partial remission (PR) after ≥4 cycles of BR had improved duration of response (DOR) with MR vs. no maintenance, whereas those in complete remission did not. These findings were confirmed in a validation cohort. In the entire study population, the known fatal adverse event rate after BR was 2·5% and did not significantly differ in those receiving MR versus no maintenance. [Correction added on 14 January 2019, after online publication: The preceding sentence has been corrected in this current version.] Within the limitations inherent to retrospective analysis, these data suggest that FL patients with a PR to BR experience prolongation of remission with MR with an acceptable safety profile.

    View details for DOI 10.1111/bjh.15720

    View details for PubMedID 30575016

    View details for PubMedCentralID PMC6486816

  • Bones in Multiple Myeloma: Imaging and Therapy. American Society of Clinical Oncology educational book. American Society of Clinical Oncology. Annual Meeting Zamagni, E., Cavo, M., Fakhri, B., Vij, R., Roodman, D. 2018; 38: 638-646

    Abstract

    Bone disease is the most frequent disease-defining clinical feature of multiple myeloma (MM), with 90% of patients developing bone lesions over the course of their disease. For this reason, imaging plays a major role in the management of disease in patients with MM. Although conventional radiography has traditionally been the standard of care, its low sensitivity in detecting osteolytic lesions has called for more advanced imaging modalities. In this review, we discuss the advantages, indications, and applications of whole-body low-dose CT (WBLDCT), 18F-fluorodeoxyglucose (FDG)-PET/CT, MRI, and other novel imaging modalities in the management of disease in patients with plasma cell dyscrasias. We also review the state of the art in treatment of MM bone disease (MMBD) and the role of bisphosphonates and denosumab, a monoclonal antibody that binds and blocks the activity of receptor activator of nuclear factor-kappa B ligand (RANKL), which was recently approved by the U.S. Food and Drug Administration for MMBD.

    View details for DOI 10.1200/EDBK_205583

    View details for PubMedID 30231385

  • Undertreatment of Older Patients With Newly Diagnosed Multiple Myeloma in the Era of Novel Therapies. Clinical lymphoma, myeloma & leukemia Fakhri, B., Fiala, M. A., Tuchman, S. A., Wildes, T. M. 2018; 18 (3): 219-224

    Abstract

    With the expanding armamentarium of therapeutic agents for multiple myeloma (MM), it is important to identify any undertreated patient populations to mitigate outcome disparities.We extracted the data for all plasma cell myeloma cases (International Classification of Disease for Oncology, third revision [ICD-O-3] code 9732) in the Surveillance, Epidemiology, End Results (SEER)-Medicare database from 2007 to 2011. The ICD-O-3 histologic code 9732 captures both active MM and smoldering/asymptomatic myeloma. We defined active MM as either claims indicating receipt of treatments approved for MM or ICD-9 codes for MM-defining clinical features, referred to as the CRAB criteria (calcium [elevated], renal failure, anemia, bone lesions). Multivariate logistic regression was performed to determine the variables that were independently associated with receipt of no treatment.Of the initial 4187 patients included in the present study, 373 had no claims indicating receipt of treatments approved for MM and had no ICD-9 codes associated with the CRAB criteria and were excluded from the analyses. Of the 3814 patients with active MM, 1445 (38%) did not have any claims confirming that they had received systemic treatment. Older age, poor performance indicators, comorbidities, African-American race, and lower socioeconomic status, including enrollment in Medicaid, were statistically significant factors associated with the receipt of no systemic treatment.In the present retrospective study of data from the SEER-Medicare database, we found that age, health status, race, and socioeconomic status were associated with receipt of MM treatment. These factors have previously been linked to reduced usage of specific treatments for MM, such as stem cell transplantation. To the best of our knowledge, however, ours is the first study to show their association with the receipt of any MM therapy.

    View details for DOI 10.1016/j.clml.2018.01.005

    View details for PubMedID 29429818

    View details for PubMedCentralID PMC5837946

  • Current and emerging treatment options for mantle cell lymphoma. Therapeutic advances in hematology Fakhri, B., Kahl, B. 2017; 8 (8): 223-234

    Abstract

    Mantle cell lymphoma (MCL) is a B-cell non-Hodgkin lymphoma with typically aggressive behavior. The genetic signature is the chromosomal translocation t(11;14)(q13;q32) resulting in overexpression of cyclin D1. Asymptomatic newly diagnosed MCL patients with low tumor burden can be closely observed, deferring therapy to the time of disease progression. Although MCL classically responds to upfront chemotherapy, it remains incurable with standard approaches. For patients in need of frontline therapy, the initial decision is whether to proceed with an intensive treatment strategy or a non-intensive treatment strategy. In general, given the unfavorable risk-benefit profile, older MCL patients should be spared intensive strategies, while younger and fit patients can be considered for intensive strategies. The bendamustine and rituximab (BR) regimen is becoming an increasingly popular treatment option among the elderly population, with improved progression-free survival (PFS) and acceptable side-effect profile. Although rituximab maintenance after R-CHOP improves survival outcomes in elderly patients, no clinical trial to date has shown statistical significance to support the use of rituximab maintenance after BR induction in older patients. In young and fit patients with MCL, an intensive strategy to maximize the length of first remission has emerged as a worldwide standard of care. With current high-dose cytarabine-containing immunochemotherapy regimens followed by autologous stem cell transplantation, the median PFS has exceeded 7 years. In the relapsed or refractory (R/R) setting, reduced intensity conditioning allogeneic hematopoietic stem cell transplantation may offer the highest likelihood of long-term survival in young R/R MCL patients, at the cost of increased risk of non-relapse mortality and chronic graft versus host disease. Novel agents targeting activated pathways in MCL cells, such as bortezomib, lenalidamide, ibrutinib and temsirolimus are now available for the management of R/R disease.

    View details for DOI 10.1177/2040620717719616

    View details for PubMedID 28811872

    View details for PubMedCentralID PMC5544150

  • Molecular landscape and sub-classification of gastrointestinal cancers: a review of literature. Journal of gastrointestinal oncology Fakhri, B., Lim, K. H. 2017; 8 (3): 379-386

    Abstract

    The historical approach of diagnosing cancer types based entirely on anatomic origin and histologic features, and the "one-size-fit-all" therapeutic approach, are inadequate in modern cancer treatment. From decades of research we now know that cancer is a highly heterogeneous disease driven by complex genetic or epigenetic alterations. The advent of various high throughput molecular tools has now enabled us to view and sub-classify each cancer type based on their distinct molecular features, in addition to histologic classification, with the promise of individualized treatment strategies tailored towards each specific subtype to improve patient outcomes. In this review, we have made an effort to systematically review the most up-to-date, leading literature in molecular analysis and/or subtyping of major gastrointestinal cancers. These include esophageal squamous cell carcinoma (ESCC), gastric cancer (GC) adenocarcinoma, pancreatic ductal adenocarcinoma (PDAC), hepatocellular carcinoma (HCC), gallbladder cancer (GBC), and colorectal cancer (CRC). For each cancer type we summarized the global mutational landscape, subgroup classification based on genomics, epigenetics, gene expression and/or proteomic analysis, and their salient clinicopathological features. We have highlighted the actionable mutations or mutational pathways that could help guide targeted therapies in the future.

    View details for DOI 10.21037/jgo.2016.11.01

    View details for PubMedID 28736626

    View details for PubMedCentralID PMC5506283

  • Donor-Derived Smoldering Multiple Myeloma following a Hematopoietic Cell Transplantation for AML. Case reports in hematology Fakhri, B., Fiala, M., Slade, M., Westervelt, P., Ghobadi, A. 2017; 2017: 3728429

    Abstract

    Posttransplant Lymphoproliferative Disorder (PTLD) is one of the most common malignancies complicating solid organ transplantation. In contrast, PTLD accounts for a minority of secondary cancers following allogeneic hematopoietic cell transplantation (HCT). Here we report on a 61-year-old woman who received an ABO-mismatched, HLA-matched unrelated donor hematopoietic cell transplantation from a presumably healthy donor for a diagnosis of acute myeloid leukemia (AML). Eighteen months following her transplant, she developed a monoclonal gammopathy. Bone marrow studies revealed 10% plasma cells, but the patient lacked clinical defining features of multiple myeloma (MM); thus a diagnosis of smoldering multiple myeloma (SMM) was established. Cytogenetic and molecular studies of the bone marrow confirmed the plasma cells were donor-derived. The donor lacks a diagnosis of monoclonal gammopathy of undetermined significance, SMM, or MM.

    View details for DOI 10.1155/2017/3728429

    View details for PubMedID 28316846

    View details for PubMedCentralID PMC5337855

  • Halfway there: the past, present and future of haploidentical transplantation. Bone marrow transplantation Slade, M., Fakhri, B., Savani, B. N., Romee, R. 2017; 52 (1): 1-6

    Abstract

    In recent years, the use of haploidentical donors for hematopoietic cell transplantation has expanded rapidly. Approximately 50% of patients requiring hematopoietic cell transplant lack a traditional donor. The use of HLA haploidentical-related donors is attractive due to nearly universal availability of this graft source. We summarize the current and future need for haploidentical donors and detail the rise of post-transplant cyclophosphamide as the dominant haploidentical approach. Further, we examine ongoing controversies in the field of haploidentical transplant, including conditioning regimens and graft source. Finally, we review the evidence available from preliminary comparative studies and discuss future direction of research.

    View details for DOI 10.1038/bmt.2016.190

    View details for PubMedID 27454072

  • Clonal Evolution in Multiple Myeloma. Clinical lymphoma, myeloma & leukemia Fakhri, B., Vij, R. 2016; 16 Suppl: S130-4

    Abstract

    Multiple myeloma (MM) is the second most common hematologic malignancy encountered among patients in the United States. The last decade has seen incremental improvements in the survival of patients with MM. These advances are, to a large extent, attributable to the addition of proteasome inhibitors and immunomodulatory drugs to the armamentarium of treatment options. The adoption of these drug classes was the result of an empiric research paradigm. However, with the application of next generation sequencing technologies, we are now starting to unravel the genomic landscape of MM. It is hoped that this will allow us to better disentangle the biology of the disease and allow for identification of new therapeutic targets. In this article, we review what we have learned to date about the mutational profile, clonal architecture, and evolution of the disease, and discuss the potential clinical implications of these findings.

    View details for DOI 10.1016/j.clml.2016.02.025

    View details for PubMedID 27521309