Biology and treatment of Richter syndrome

Abstract

Richter syndrome (RS) is the development of an aggressive lymphoma in patients with chronic lymphocytic leukemia (CLL). Two pathologic variants of RS are recognized, namely the diffuse large B-cell lymphoma (DLBCL) variant, and the rare Hodgkin lymphoma (HL) variant. Histologic documentation is mandatory to diagnose RS. The clinical suspicion of RS should be based on clinical signs and symptoms. Differential diagnosis between CLL progression and RS and choice of the biopsy site may take advantage of PET/CT. Molecular lesions of regulators of proliferation (CDKN2A, NOTCH1, MYC) and apoptosis (TP53) overall associate with ~90% of DLBCL-type RS, while the biology of the HL-type RS is largely unknown. The prognosis of the DLBCL-type RS is unfavourable, while the outcome of HL-type RS appears to be better. The most important RS prognostic factor is the clonal relationship between the CLL and the aggressive lymphoma clones, with clonally unrelated RS having a better prognosis. Rituximab-containing combination chemotherapy for DLBCL is the most widely treatment in DLBCL-type RS. Fit patients who respond to induction therapy should be offered stem cell transplant to prolong survival. ABVD is the preferred regimen for the HL-type RS and stem cell transplant consolidation is less used in this condition.