Expert Opinion on Drug Discovery

ISSN: 1746-0441 (Print) 1746-045X (Online) Journal homepage: http://www.tandfonline.com/loi/iedc20

The discovery and the development of

bendamustine for the treatment of non-Hodgkin
lymphoma

Wataru Munakata & Kensei Tobinai

To cite this article: Wataru Munakata & Kensei Tobinai (2016): The discovery and the
development of bendamustine for the treatment of non-Hodgkin lymphoma, Expert Opinion
on Drug Discovery, DOI: 10.1080/17460441.2016.1233174

To link to this article: http://dx.doi.org/10.1080/17460441.2016.1233174

Accepted author version posted online: 06

Sep 2016.
Published online: 06 Sep 2016.

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Download by: [Cornell University Library] Date: 10 September 2016, At: 13:40
Publisher: Taylor & Francis

Journal: Expert Opinion on Drug Discovery

DOI: 10.1080/17460441.2016.1233174

Drug Discovery Case History:

The discovery and the development of bendamustine for the treatment of
non-Hodgkin lymphoma

Wataru Munakata, MD, and Kensei Tobinai, MD, PhD

Affiliation and Address

Wataru Munakata, MD

Clinical Staff, Department of Hematology, National Cancer Center Hospital, Tokyo

5-1-1Tsukiji, Chuo-ku, Tokyo 104-0045, JAPAN

Phone: +81-33542-2511 FAX: +81-33542-3815

E-mail: wmunakat@ncc.go.jp

Kensei Tobinai, MD, PhD

Chief, Department of Hematology, National Cancer Center Hospital

5-1-1Tsukiji, Chuo-ku, Tokyo 104-0045, JAPAN

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 Phone: +81-33542-2511 FAX: +81-33542-3815

E-mail: ktobinai@ncc.go.jp

Abstract
Introduction: Non-Hodgkin lymphoma (NHL) is a heterogeneous group of lymphoid

malignancies. The treatment strategy for patients with NHL had remained unchanged until

the advent of the era of molecular targeting agents. Although rituximab-containing

chemotherapy has improved the response rates and survival of patients with B-cell NHL

(B-NHL), several subtypes of B-NHL, especially indolent B-NHL and mantle cell lymphoma

(MCL), remain incurable. Therefore, novel treatment modalities for B-NHL, especially for

indolent B-NHL and MCL, are needed. Bendamustine is an old, but unique, multifunctional

cytotoxic agent that exhibits structural similarity to alkylating agents and purine analogs.

Areas covered: The basic aspects and preclinical development of bendamustine are

summarized, followed by a discussion of the clinical development of bendamustine-based

treatments for indolent B-NHL and MCL.

Expert opinion: Bendamustine monotherapy or the use of bendamustine in combination

with rituximab is highly effective against various types of hematological malignancies,

especially relapsed or refractory indolent B-NHL, and exhibits an acceptable toxicity profile.

Furthermore, bendamustine plus rituximab might be a promising treatment option for

patients with untreated indolent B-NHL. Therefore, bendamustine has the potential to play

an important role in the treatment of malignant lymphoma.

Keywords: bendamustine, malignant lymphoma, indolent B-cell non-Hodgkin’s

lymphoma, follicular lymphoma, mantle cell lymphoma

2
1. Introduction
Non-Hodgkin lymphoma (NHL) is a heterogeneous group of lymphoid

malignancies, comprising 3 to 5% of all malignancies in the USA and worldwide. It is

estimated that there will be a total of 72,580 new cases of NHL and 20,150 deaths due to

NHL in the USA in 20161. The treatment of NHL had remained unchanged until the advent of

the era of molecular targeting agents.2 Rituximab is the first developed anti-CD20

monoclonal antibody and initially incorporated into the treatment of B-cell NHL (B-NHL).

Although the use of rituximab in combination with chemotherapy has improved the

prognosis of patients with B-NHL, including follicular lymphoma (FL)3 and diffuse large

B-cell lymphoma (DLBCL)4, 5, indolent form of B-NHL, such as FL, marginal zone lymphoma

(MZL), small lymphocytic lymphoma (SLL)/chronic lymphocytic leukemia (CLL), and

lymphoplasmacytic lymphoma (LPL), remain incurable with the current

chemoimmunotherapy alone. Furthermore, mantle cell lymphoma (MCL), a distinct type of

B-NHL defined by the presence of the t(11;14) translocation, also cannot be cured with

conventional chemoimmunotherapy. Therefore, novel treatment modalities for NHL,

especially indolent B-NHL including MCL, are needed.

On the other hand, there have been marked advances in our knowledge about the

pathology and biology of malignant lymphoma, as well as its molecular characterization.

Recent scientific studies have revealed a lot of the genetic and molecular mechanisms that

cause malignant lymphoma. Based on the results of basic research, a number of novel

molecular targeting agents have been developed and introduced into clinical practice. For

example, ibrutinib, a Bruton’s tyrosine kinase (BTK) inhibitor;6, 7 idelalisib, a

3
phosphatidylinositol-3-kinase (PI3K) inhibitor; 8, 9 and venetoclax, a B-cell lymphoma-2

(BCL-2) inhibitor,10 have recently been developed as effective treatments for relapsed or

refractory CLL or MCL.

In this era of molecular targeting agents, the development of novel cytotoxic agents

might be neglected. However, bendamustine is an old, but unique multifunctional cytotoxic

agent that exhibits structural similarity to alkylating agents and purine analogs. It has

demonstrated clinical activity against various types of hematological malignancies, including

indolent B-NHL and MCL, when used as a monotherapy or in combination with other

chemotherapeutic agents. Despite the use of molecular targeting therapies are

revolutionizing the treatment strategies for malignant lymphoma, however, older drugs such

as bendamustine recently has proven to be highly effective in many lymphoproliferative

disorders. In this review, we will discuss the use of bendamustine to treat NHL, especially

indolent B-NHL.

2. Preclinical development
Bendamustine was initially synthesized in the early 1960s in the former East

German Democratic Republic by Dr Ozegowski et al.11 The latter group intended to

synthesize a nitrogen mustard compound that was less toxic than but at least as effective as

other alkylating agents. Chemically, bendamustine is known as

4-[5-[bis(2-chloroethyl)amino]-1-methyl-benzoimidazol-2-yl] butyric acid hydrochloride.

Structurally, bendamustine is composed of three elements, a mechlorethamine (nitrogen

mustard) group, a benzimidazole ring, and a butyric acid side chain (Figure 1). The

mechlorethamine group confers alkylator properties and produces double-strand breaks in

DNA, the benzimidazole ring is similar in structure to those found in purine analogs and

4
might confer antimetabolite properties, and the butyric acid side chain increases water

solubility.12

In vitro studies have indicated that bendamustine has a novel mechanism of action.

In cancer cell lines, bendamustine demonstrated incomplete cross-resistance with other

alkylating agents (e.g., cyclophosphamide, melphalan, and carmustine) because of a

substance-specific interaction between bendamustine and DNA.13 Furthermore,

bendamustine-induced DNA damage is more extensive and more durable than that

produced by other alkylating agents, and the cellular DNA repair mechanism that is

activated in response to such damage is different from that activated by the damage caused

by other alkylating agents.13 Gene expression profiling confirmed these findings, identifying

a distinct pattern of activity that is induced in response to bendamustine and is unrelated to

the pattern of activity induced by other alkylating agents.12 In addition to DNA damage, the

cellular stress response, and apoptosis, bendamustine inhibits mitotic checkpoints and

induces mitotic catastrophe. Bendamustine does not show cross-resistance with other

cytotoxic agents and is active in primary NHL cells that are refractory to cytotoxic agents

such as cyclophosphamide, doxorubicin, and etoposide.12 In the National Cancer Institute’s

COMPARE analysis,12 it was demonstrated that the sensitivity patterns of

cyclophosphamide, chlorambucil, and melphalan exhibited a high degree of correlation. In

contrast, the sensitivity pattern of bendamustine was not strongly correlated with that of any

other agent tested. These results suggest that bendamustine has unique mechanistic

features compared with conventional alkylating agents.

Chow et al. investigated the in vitro activity of bendamustine in combination with

other established cytotoxic agents. The combined use of bendamustine and mitoxantrone or

doxorubicin resulted in antagonistic effects in the tested cell lines. On the other hand, the

combined use of bendamustine and cladribine exhibited synergistic in vitro activity against

5
the tested cell lines.14 Furthermore, bendamustine and cytarabine showed highly synergism

on B-lymphoma cells including MCL and T-lymphoma cells, overcoming resistance to the

single agents.15, 16 Preclinical studies supported the use of bendamustine in combination

with rituximab, as this combination displayed a synergistic interaction.17 When both agents

were administered to severe combined immunodeficiency mice with Daudi xenografts, the

combination treatment had a more profound inhibitory effect on tumor growth than either

agent alone. Similar effects were obtained with FL cell lines and ex vivo cells from patients

with CLL. Furthermore, the in vitro addition of rituximab has been shown to reduce the dose

of bendamustine required to induce apoptosis in CD20-positive cell lines. 18 Based on these

preclinical observations, clinical studies of bendamustine were initiated.

3. Pharmacokinetic profile of bendamustine

Bendamustine is primarily metabolized via the hydrolysis of its mechlorethamine

group into two metabolites with little or no activity: monohydroxy-bendamustine (HP1) and

dihydroxy-bendamustine (HP2).19 Bendamustine also undergoes phase 1 metabolism via

cytochrome P450 (CYP) 1A2-catalyzed oxidative pathways, which results in two active

circulating metabolites: γ-hydroxybendamustine (M3) and N-desmethyl-bendamustine (M4).

20, 21
M3 is produced by γ-oxidation of the butyric acid side chain, and M4 is produced by

demethylation of the benzimidazole ring. Although bendamustine has been used in the

clinical setting for a long time, there is limited data on its pharmacokinetic (PK) profile.

According to the PK analyses performed in a phase III study involving patients with

rituximab-refractory indolent B-NHL and a human mass balance study,22, 23 bendamustine is

metabolized via multiple pathways. Bendamustine has a short effective t1/2 (~40 minutes),

and its maximum plasma concentration (Cmax) is typically reached near to the end of the

infusion period (~1 hour). In addition, it has a low concentration at 12 hours to Cmax ratio

6
(mean: 1:25,000). Thus, although the PK profile of bendamustine during the administration

of multiple doses of the drug have not been studied, dose accumulation is not expected to

occur when the standard dosing schedule of two consecutive days in a 21- or 28-day cycle

is employed. Therefore, the single-dose PK profile of bendamustine is considered to be

representative of its multiple-dose PK profile.

The PK profiles of bendamustine have also been evaluated in a Japanese phase I

study of bendamustine in patients with relapsed or refractory indolent B-NHL or MCL.24 The

mean Cmax of bendamustine was 7.2 ± 3.3 μg/mL and 8.6 ± 4.5 μg/mL after the

administration of bendamustine at doses of 90 and 120 mg/m2, respectively. In both dosing

groups, Cmax was reached near to the end of the bendamustine administration period (at

approximately 1 hour). Bendamustine was rapidly eliminated from the patients’ plasma, and

its mean t1/2 was 28-32 minutes in both dosing groups. In this PK analysis, no racial

differences were detected between Western and Japanese people.

4. Clinical development

4.1 Clinical development of bendamustine treatment for relapsed or

refractory indolent B-NHL or MCL
Based on the promising results of German studies,25, 26 two single-agent phase II

studies were conducted in the US. The first multicenter phase II study of bendamustine for

patients with rituximab-refractory indolent B-NHL and transformed B-NHL was conducted by

Dr. Friedberg et al.27 The primary endpoint was the overall response rate (ORR), and the

secondary endpoints included safety, progression-free survival (PFS), and the duration of

the response (DOR). Bendamustine was intravenously administered on days 1 and 2 of a

21-day cycle for 6 to 12 cycles at a dose of 120 mg/m2. A total of 76 patients were enrolled in

this phase II study, and 74 were evaluated in the efficacy analysis. Of these, 61% had FL,

7
and 20% had transformed B-NHL. Among the 74 evaluable patients, the ORR was 77%

(57/74), and 11 complete responses (CR) and 14 unconfirmed CR (CRu) were recorded.

The median PFS was 7.1 months (95% confidence interval [CI]: 6.0-8.9 months) for all

patients, 8.3 months (95% CI: 6.6-10.9 months) for patients with indolent histologies, and

4.2 months (95% CI: 2.7-5.1 months) for those with transformed B-NHL. The median DOR

for all responders was 6.7 months (95% CI: 5.1-9.9 months), 9.0 months (95% CI: 5.8-16.7

months) for patients with indolent histologies, and 2.3 months (95% CI: 1.7-5.1 months) for

those with transformed B-NHL. The most frequent non-hematological toxicities included

nausea/vomiting, fatigue, constipation, anorexia, fever, coughing, and diarrhea. The grade 3

or 4 hematological toxicities experienced by the patients included neutropenia (54%),

thrombocytopenia (25%), and anemia (12%). Overall, these findings demonstrated that

bendamustine produced durable objective responses and exhibited acceptable toxicity in

heavily pretreated patients with rituximab-refractory, indolent B-NHL. The second phase II

study of bendamustine was reported by Dr. Kahl et al.28 In this multicenter phase II study,

the efficacy and toxicity of single-agent bendamustine were evaluated in patients with

rituximab-refractory indolent B-NHL. The primary endpoints were the ORR and DOR, and

the secondary endpoints included the safety profile and PFS. Bendamustine was

administered using the same dosing schedule as was employed in the previous phase II

study for 6 to 8 cycles. A total of 100 patients were enrolled, and their histological subtypes

included FL (62%), SLL (21%), and MZL (16%). The ORR was 75% (95% CI: 65-83%), and

14 CR and 3 CRu were observed. The median DOR of the patients who achieved responses

was 9.2 months (95% CI: 7.1-10.8 months), and the median PFS for all patients was 9.3

months (95% CI: 8.1-11.9 months). The toxicity profile of single-agent bendamustine

exhibited the same tendencies as were observed in the previous phase II study. These two

studies demonstrated that bendamustine is highly active in patients with rituximab-refractory

8
indolent B-NHL. Based on these results, the US Food and Drug Administration (FDA)

approved bendamustine for use as a treatment for rituximab-refractory indolent B-NHL.

Given the promising results obtained during the use of bendamustine as a single

agent, two phase II studies were conducted to evaluate the efficacy of combination

treatment with bendamustine and rituximab (BR, 90 mg/m2 on days 1 and 2, every 4 weeks).

The first phase II study of such treatment was reported by a German group, the Study Group

indolent Lymphomas (StiL).29 A total of 63 patients with relapsed or refractory indolent

B-NHL or MCL were enrolled, and their histological subtypes included FL (38%), MCL (25%),

LPL (27%), and MZL (10%). Patients that had previously received rituximab treatment were

excluded. The ORR was 90% (95% CI: 80-96%), and 38 patients achieved CR (%CR: 60%,

[95% CI: 47-72%]). The median PFS was 24 months (95% CI: 5 to ≥44 months). Among the

patients with MCL, the ORR was 75% (95% CI: 48-93%) and the %CR was 50%. The

associated non-hematological toxicities were generally mild, and grade 3-4 leukopenia (16%

of cycles) was the most common hematological toxicity. These findings have been

confirmed by a US multicenter study reported by Dr. Robinson et al.30 In the latter study, 67

patients with indolent B-NHL or MCL who relapsed after chemotherapy with or without

rituximab, but did not have rituximab-refractory B-NHL, were enrolled. Their histological

subtypes included FL (61%), MCL (18%), CLL/SLL (15%), LPL (3%), and MZL (3%). Among

the 66 evaluable patients, the ORR was 92%, and 41% and 14% of patients achieved CR

and CRu, respectively, and no difference was seen between the response rates of the

patients with indolent B-NHL and MCL. The median PFS was 23 months (95% CI: 20-26

months), and the median DOR was 21 months (95% CI: 19-22 months). The results of these

two studies demonstrated that BR is an effective combination therapy and exhibits

acceptable toxicity in patients with relapsed or refractory indolent B-NHL or MCL.

9
 Furthermore, on the basis of these results the StiL conducted a randomized,

non-inferiority phase III study comparing the efficacy and safety of combination treatment

with bendamustine (the BR arm) or fludarabine (the FR arm) and rituximab in patients with

relapsed or refractory indolent B-NHL or MCL.31 Patients whose disease was refractory to

rituximab, bendamustine, or purine analogs were excluded. The primary endpoint was PFS,

and the secondary endpoints included the ORR, %CR, overall survival (OS), and safety. The

non-inferiority of BR compared with FR was defined as a difference of less than 15% in

1-year PFS. A total of 230 patients were enrolled and randomly assigned to receive BR

(n=116) or FR (n=114). However, 11 were not eligible and so were excluded from the

analysis. Therefore, 219 patients were included in the analysis, 114 from the BR arm and

105 from the FR arm. The dosage schedule was as follows: rituximab (375 mg/m2 on day 1)

plus either bendamustine (90 mg/m2 on days 1 and 2) or fludarabine (25 mg/m2 on days 1-3)

every 4 weeks for a maximum of 6 cycles. At the median follow-up of 96 months, the median

PFS was 34.2 months (95% CI: 23.5-52.7 months) in the BR arm and 11.7 months (95% CI:

8.0-16.1 months) in the FR arm (hazard ratio [HR]: 0.54 [95% CI: 0.38-0.72], p <0.0001).

Subgroup analysis showed that the improvement in PFS seen in the BR arm applied to

patients with FL (HR: 0.54, 95% CI: 0.34-0.87), MCL (HR: 0.45, 95% CI: 0.22-0.76), or SLL

(HR: 0.28, 95% CI: 0.07-0.62). The ORR in the BR and FR arms were 82% and 51%,

respectively (p <0.0001). The patients treated with BR exhibited significantly longer median

OS than those treated with FR (109.7 months [95% CI: 50.2 months - not reached] versus

49.1 months [95% CI: 36.2-59.0 months]; HR: 0.65, 95% CI: 0.45-0.91, p=0.012). The safety

profiles of both arms were similar, and the most common adverse events were

myelosuppression and infections. The results of this study suggested that BR is the

preferred treatment option for patients with relapsed or refractory indolent B-NHL or MCL.

10
 In addition, Italian group conducted a phase II study of BR plus intermediate dose of

cytarabine (R-BAC) in patients with MCL age ≥65 years who were previously untreated or

relapsed or refractory after one prior immunochemotherapy.32 In this study, 40 patients (20

untreated patients) received R-BAC (rituximab, 375 mg/m2 on day 1, bendamustine 70

mg/m2 on days 1 and 2, cytarabine, 800mg/m2 on day 3) every 4 weeks. The ORR was 90%

and the %CR was 83% for all patients. The 2-years PFS rate was 90% (95% CI: 90-100%)

for untreated patients and 70% (95% CI: 60-80%) for relapsed or refractory patients. Even

though relatively small number of patients were enrolled, these results indicated that R-BAC

is an active regimen for patients with relapsed or refractory MCL.

4.2 Clinical development of bendamustine treatment for untreated

indolent B-NHL and MCL
The efficacy of bendamustine for relapsed or refractory indolent B-NHL or MCL has

been confirmed by several clinical studies, as mentioned above. On the other hand, little is

known about the utility of bendamustine as a treatment for untreated indolent B-NHL or MCL.

StiL conducted a randomized non-inferiority phase III study to assess the efficacy and safety

of BR versus rituximab plus CHOP (cyclophosphamide, doxorubicin, vincristine, and

prednisone; R-CHOP), which is considered to be the standard first-line treatment for

patients with indolent B-NHL or MCL.33 The primary endpoint was PFS, and the secondary

endpoints included the ORR, %CR, OS, and safety. The non-inferiority of BR compared with

R-CHOP was defined as a difference of less than 10% in 3-year PFS. In this study, 274

patients were assigned to the BR arm, and 275 were allocated to the R-CHOP arm.

However, 35 patients were excluded from the analysis. Therefore, a total of 514 patients

were included in the analysis, 261 from the BR arm and 253 from the R-CHOP arm. At the

median follow-up of 45 months, the median PFS of the BR arm was significantly longer than

11
that of the R-CHOP arm (69.5 months [95% CI: 26.1 months - not reached] versus 31.2

months [95% CI: 15.2-65.7 months]; HR: 0.58 [95% CI: 0.44-0.74], p <0.0001). This

significant PFS benefit was observed in all histological subtypes, except for MZL. Neither

the ORR nor OS differed between the two treatment arms; however, the %CR of the BR arm

was significantly higher than that of the R-CHOP arm (40% versus 30%; p=0.021). BR was

better tolerated than R-CHOP and resulted in low incidences of alopecia, hematological

toxicities, infections, peripheral neuropathy, and stomatitis. Erythematous skin reactions

were more common in the BR arm than in the R-CHOP arm. Based on the results of this

study, BR is considered to be a better first-line treatment regimen than R-CHOP for patients

with untreated indolent B-NHL or MCL.

Furthermore, another randomized, non-inferiority, global phase III study (the

BRIGHT study) was conducted to evaluate the efficacy and safety of BR versus R-CHOP or

R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone) for patients with

untreated indolent B-NHL or MCL.34 The primary endpoint was the %CR, and the secondary

endpoints included the ORR, PFS, DOR, OS, and safety. The non-inferiority of BR

compared with R-CHOP/R-CVP was defined as follows: a %CR ratio of >0.88 (non-inferior

margin). Among the evaluable patients, there were 213 patients in the BR arm and 206

patients in the R-CHOP/R-CVP arm. The %CR was 31% (95% CI: 25.3-38.2%) in the BR

arm and 25% (95% CI: 19.5-31.7%) in the R-CHOP/R-CVP arm. It was confirmed that BR is

not inferior to R-CHOP/R-CVP (p=0.0225). The ORR of the BR and R-CHOP/R-CVP arms

were 97% (95% CI: 93.3-98.7%) and 91% (95% CI: 86.0-94.4%), respectively (p=0.0102).

The toxicity profiles of the two treatment arms were different. BR was associated with a

higher rate of lymphocytopenia, whereas R-CHOP/R-CVP was associated with an increased

risk of neutropenia. BR was also associated with a slightly increased risk of opportunistic

infections and nausea, but decreased frequencies of peripheral neuropathy/paresthesia and

12
alopecia. These results indicated that BR is not inferior to R-CHOP/R-CVP with regard to

the clinical response and results in acceptable toxicity profiles in patients with untreated

indolent B-NHL or MCL. However, further follow-up is needed to determine the PFS and OS

of both arms.

Based on the results of a phase III study (PRIMA), 2-years of rituximab

maintenance therapy after immunochemotherapy (R-CHOP, R-CVP, or R-FCM [fludarabine,

cyclophosphamide, and mitoxantrone]) was shown to improve PFS in patients with

untreated high tumor burden FL.35 Furthermore, rituximab maintenance therapy after

R-CHOP improved PFS and OS in patients with untreated MCL.36 On the other hand, the

role of rituximab maintenance therapy after BR is unknown. StiL conducted a randomized

phase III study to compare 2-years rituximab maintenance therapy versus observation after

BR in patients with untreated indolent B-NHL or MCL. The subgroup analysis of this study

showed that rituximab maintenance therapy did not improve PFS or OS after BR in patients

with untreated MCL.37 For MCL treated with BR, rituximab maintenance therapy might be

omitted. But further investigations are warranted to confirm these results.

4.3 Clinical development of bendamustine treatment for DLBCL

There are limited data regarding the use of bendamustine as a treatment for

DLBCL.38 A multicenter phase II study was conducted to assess the efficacy and safety of

BR for relapsed or refractory DLBCL in Japan and Korea.39 A total of 63 patients were

enrolled and received 375 mg/m2 rituximab on day 1 and 120 mg/m2 bendamustine on days

2 and 3 of each 21-day cycle for up to 6 cycles. The ORR was 62.7% (95% CI: 49.1-75.0%),

and the %CR was 37.3% (95% CI: 25.0-50.9%). The median PFS was 6.7 months (95% CI:

3.6-13.7 months). Another phase II study was conducted to assess the efficacy and safety of

BR for untreated DLBCL.40 In this study, 23 patients aged ≥ 65 years who were poor

13
candidates for R-CHOP were enrolled with median age of 80 years. The ORR was 78% and

the %CR was 52% (95% CI: 30.6-73.2%). The median OS was 10.2 months (95% CI:

3.8-13.3 months) and the median PFS was 5.4 months (95% CI: 3.8-10.2 months). BR

demonstrated high response rates as front line treatment in frail older patients with DLBCL,

but survivals were short. These two results indicated that BR is a promising salvage regimen

for patients with relapsed or refractory DLBCL. However, no further investigations of the use

of bendamustine to treat DLBCL have since been conducted.

5. Prolonged lymphocytopenia after bendamustine treatment

Bendamustine is generally well tolerated, as described above. It is known that the

toxicity profiles of bendamustine-containing regimens and conventional

chemoimmunotherapies like R-CHOP or R-CVP differ. In particular, lymphocytopenia and

opportunistic infections are more common in patients treated with bendamustine-containing

regimens. It was reported that lymphocyte recovery was impaired in patients with CLL or

indolent B-NHL that were treated with BR.41 Cytomegalovirus or Epstein-Barr virus

reactivation is another potential concern. Furthermore, according to a retrospective analysis,

the recovery of lymphocyte and CD4-positive T-cell counts to baseline levels was observed

at 7-9 months after the completion of bendamustine-containing treatment.42 Thus,

prophylaxis against Pneumocystis jiroveci and varicella zoster virus might be considered for

patients that are treated with bendamustine-containing regimens, at least for the first 7-9

months.

6. Conclusions
Bendamustine monotherapy and combination treatment with bendamustine and

rituximab have been shown to be highly effective against various types of hematological

14
malignancies, especially indolent B-NHL, and MCL, and exhibit acceptable toxicity profiles.

Based on the results of several clinical studies of bendamustine, it can be said that

bendamustine is one of the key agents for treating malignant lymphoma. In this era of

molecular targeting agents, bendamustine-based combination therapy involving novel

molecular targeting agents is expected to improve the clinical outcomes of patients with

malignant lymphoma.

Recently, the results of bendamustine in combination with molecular targeting

agents have been reported. Marddock et al. reported the results of phase I/Ib study of BR

plus ibrutinib in patients with B-NHL and showed that this combination therapy has a

promising efficacy and tolerability, especially for MCL and FL.43 Based on the results of this

study, two randomized phase III studies of BR with or without ibrutinib were conducted for

patients with untreated MCL or relapsed FL, and patient’s enrollment was completed.

Furthermore, lenalidomide in combination with BR was shown to be highly effective for

MCL.44, 45 However, high degree of severe infections were observed. Future clinical studies

are needed to investigate the suitable molecular targeting agents in combination with BR.

7. Expert opinion
As indolent B-cell malignancies, including MCL, are incurable, patients with these

diseases invariably relapse and require a succession of treatments. Although it remains

incurable, the outcomes of indolent B-NHL have improved, and its median OS is currently

>12 years. In such cases, decisions regarding treatment selection should be based on a

number of factors, including the previously administered treatments, the duration of the

previous response, the patient’s age, comorbidities, and the goals of therapy. Therefore,

effective treatment modalities with acceptable toxicity profiles are needed to treat these

diseases. Recently, a variety of novel agents have been developed as treatments for

15
indolent B-NHL, including PI3K inhibitors (idelalisib, duvelisib, and copanlisib), a BTK

inhibitor (ibrutinib), a BCL-2 inhibitor (venetoclax), an immunomodulatory agent

(lenalidomide), antibody-drug conjugates (polatuzumab vedotin and pinatuzumab vedotin),

a novel anti-CD20 monoclonal antibody (obinutuzumab), chimeric antigen receptor T-cell

therapy, immune checkpoint inhibitors (pidilizumab, nivolumab, and pembrolizumab), and

others. Bendamustine is not a novel agent, but has been re-evaluated in the last decade.

Bendamustine is highly effective and provides durable responses in patients with relapsed

or refractory indolent B-NHL, including MCL. The effectiveness and response durability of

bendamustine with or without rituximab were confirmed in several clinical studies. In

patients with relapsed or refractory indolent B-NHL, the response rate brought about by

bendamustine treatment is at least comparable with that induced by Y90-ibritumomab

tiuxetan radioimmunotherapy. On the other hand, in the first-line setting the role of

bendamustine remains controversial, even though two randomized clinical trials comparing

BR with R-CHOP/R-CVP demonstrated that BR exhibits non-inferiority. In the first trial by

StiL, the results obtained in the R-CHOP arm seemed to be inferior to those reported in

other studies, and so the quality of this study might not be very high. In the BRIGHT study,

the primary endpoint was %CR, and data on PFS and OS were not collected in a rigorous

manner. Therefore, we need more long-term follow-up data in order to be able to judge

whether BR is superior to other conventional chemoimmunotherapies like R-CHOP in terms

of its efficacy and toxicity.

It is known that the toxicity profiles of BR and R-CHOP differ. Although R-CHOP is

the most widely used first-line treatment for indolent B-NHL, late cardiotoxicity due to

doxorubicin is a serious problem in clinical practice, especially in elderly patients. Peripheral

neuropathy due to vincristine and alopecia can also impair patients’ quality of life. The use of

bendamustine-containing regimens might help to avoid these adverse events. In addition,

16
the feasibility of re-treatment with R-CHOP is limited by the cumulative dose of

anthracyclines. On the other hand, in a retrospective review 46 re-treatment with

bendamustine was found to be feasible, especially in patients that had previously achieved

long-term remission.

Although it might be difficult for BR to totally replace R-CHOP as a first-line

treatment for indolent B-NHL, bendamustine has the potential to play an important role in

the treatment of indolent B-NHL. It is expected that bendamustine will not only improve the

therapeutic outcomes of patients with indolent B-NHL, but also serve as a backbone for the

future development of novel regimens, including new molecular targeting agents.

Funding:

This work was supported in part by the National Cancer Center Research Fund 26-A-4.

Declaration of Interest:

K Tobinai received research funding and honoraria from Eisai Co., Ltd that sells

bendamustine. The authors have no other relevant affiliations or financial involvement with

any organization or entity with a financial interest in or financial conflict with the subject

matter or materials discussed in the manuscript apart from those disclosed.

Article highlights
 Bendamustine is an old, but unique multifunctional cytotoxic agent that exhibits

structural similarity to alkylating agents and antimetabolites.

 It has demonstrated clinical activity against various types of hematological malignancies,

especially indolent B-NHL and MCL.

17
 Bendamustine is generally well tolerated. Furthermore, the toxicity profiles of

bendamustine-containing regimens and conventional chemoimmunotherapies are

different.

 Bendamustine is expected to serve as a backbone for the future development of novel

regimens, including new molecular targeting agents.

 The results of bendamustine in combination with molecular targeting agents, such as

ibrutinib and lenalidomide, have been reported and showed a promising efficacy.

 Future clinical studies are needed to investigate suitable molecular targeting agents in

combination with bendamustine.

References
1. American Cancer Society. Cancer Facts & Figures 2016. Atlanta, GA: American

Cancer Society, 2016.

2. Younes A. Beyond chemotherapy: new agents for targeted treatment of lymphoma.

Nat Rev Clin Oncol 2011;8:85-96.

3. Hiddemann W, Kneba M, Dreyling M, et al. Frontline therapy with rituximab added to

the combination of cyclophosphamide, doxorubicin, vincristine, and prednisone

(CHOP) significantly improves the outcome for patients with advanced-stage follicular

lymphoma compared with therapy with CHOP alone: results of a prospective

randomized study of the German Low-Grade Lymphoma Study Group. Blood

2005;106:3725-32.

4. Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared

with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med

2002;346:235-42.

5. Pfreundschuh M, Trumper L, Osterborg A, et al. CHOP-like chemotherapy plus

18
 rituximab versus CHOP-like chemotherapy alone in young patients with

good-prognosis diffuse large-B-cell lymphoma: a randomised controlled trial by the

MabThera International Trial (MInT) Group. Lancet Oncol 2006;7:379-91.

6. Byrd JC, Brown JR, O'Brien S, et al. Ibrutinib versus ofatumumab in previously treated

chronic lymphoid leukemia. N Engl J Med 2014;371:213-23.

7. Wang ML, Rule S, Martin P, et al. Targeting BTK with ibrutinib in relapsed or refractory

mantle-cell lymphoma. N Engl J Med 2013;369:507-16.

8. Furman RR, Sharman JP, Coutre SE, et al. Idelalisib and rituximab in relapsed chronic

lymphocytic leukemia. N Engl J Med 2014;370:997-1007.

9. Gopal AK, Kahl BS, de Vos S, et al. PI3Kdelta inhibition by idelalisib in patients with

relapsed indolent lymphoma. N Engl J Med 2014;370:1008-18.

10. Roberts AW, Davids MS, Pagel JM, et al. Targeting BCL2 with Venetoclax in Relapsed

Chronic Lymphocytic Leukemia. N Engl J Med 2016;374:311-22.

11. Ozegowski W, Krebs D: IMET 3393,

(-[1-Methyl-5-bis-(β-chloroethyl)-amino-benzimidazolyl-(2)]-butyric acid hydrochloride,

a new cytostatic agent from among the series of benzimidazole mustard compounds.

Zbl Pharm 1971;110:1013-1019.

12. Leoni LM, Bailey B, Reifert J, et al. Bendamustine (Treanda) displays a distinct pattern

of cytotoxicity and unique mechanistic features compared with other alkylating agents.

Clin Cancer Res 2008;14:309-17.

* This study demonstrated the in vivo and in vitro analysis of bendamustine.

13. Strumberg D, Harstrick A, Doll K, et al. Bendamustine hydrochloride activity against

doxorubicin-resistant human breast carcinoma cell lines. Anticancer Drugs

1996;7:415-21.

14. Chow KU, Boehrer S, Geduldig K, et al. In vitro induction of apoptosis of neoplastic

19
 cells in low-grade non-Hodgkin's lymphomas using combinations of established

cytotoxic drugs with bendamustine. Haematologica 2001;86:485-93.

15. Visco C, Castegnaro S, Chieregato K, et al. The cytotoxic effects of bendamustine in

combination with cytarabine in mantle cell lymphoma cell lines. Blood Cells Mol Dis

2012;48:68-75.

16. Castegnaro S, Visco C, Chieregato K, et al. Cytosine arabinoside potentiates the

apoptotic effect of bendamustine on several B- and T-cell leukemia/lymphoma cells

and cell lines. Leuk Lymphoma 2012;53:2262-8.

17. Rummel MJ, Chow KU, Hoelzer D, et al. In vitro studies with bendamustine: enhanced

activity in combination with rituximab. Semin Oncol 2002;29:12-4.

18. Chow KU, Sommerlad WD, Boehrer S, et al. Anti-CD20 antibody (IDEC-C2B8,

rituximab) enhances efficacy of cytotoxic drugs on neoplastic lymphocytes in vitro: role

of cytokines, complement, and caspases. Haematologica 2002;87:33-43.

19. Preiss R, Sohr R, Matthias M, et al. [The pharmacokinetics of bendamustine

(Cytostasane) in humans]. Pharmazie 1985;40:782-4.

20. Teichert J, Baumann F, Chao Q, et al. Characterization of two phase I metabolites of

bendamustine in human liver microsomes and in cancer patients treated with

bendamustine hydrochloride. Cancer Chemother Pharmacol 2007;59:759-70.

21. Weber H, Amlacher R, Preiss R, et al. [Pharmacokinetics of bendamustin (Cytostasan)

in B6D2F1-mice]. Pharmazie 1991;46:589-91.

22. Dubbelman AC, Rosing H, Darwish M, et al. Pharmacokinetics and excretion of

14C-bendamustine in patients with relapsed or refractory malignancy. Drugs R D

2013;13:17-28.

23. Owen JS, Melhem M, Passarell JA, et al. Bendamustine pharmacokinetic profile and

exposure-response relationships in patients with indolent non-Hodgkin's lymphoma.

20
 Cancer Chemother Pharmacol 2010;66:1039-49.

24. Ogura M, Uchida T, Taniwaki M, et al. Phase I and pharmacokinetic study of

bendamustine hydrochloride in relapsed or refractory indolent B-cell non-Hodgkin

lymphoma and mantle cell lymphoma. Cancer Sci 2010;101:2054-8.

25. Bremer K. High rates of long-lasting remissions after 5-day bendamustine

chemotherapy cycles in pre-treated low-grade non-Hodgkin's-lymphomas. J Cancer

Res Clin Oncol 2002;128:603-9.

26. Heider A, Niederle N. Efficacy and toxicity of bendamustine in patients with relapsed

low-grade non-Hodgkin's lymphomas. Anticancer Drugs 2001;12:725-9.

27. Friedberg JW, Cohen P, Chen L, et al. Bendamustine in patients with

rituximab-refractory indolent and transformed non-Hodgkin's lymphoma: results from a

phase II multicenter, single-agent study. J Clin Oncol 2008;26:204-10.

28. Kahl BS, Bartlett NL, Leonard JP, et al. Bendamustine is effective therapy in patients

with rituximab-refractory, indolent B-cell non-Hodgkin lymphoma: results from a

Multicenter Study. Cancer 2010;116:106-14.

29. Rummel MJ, Al-Batran SE, Kim SZ, et al. Bendamustine plus rituximab is effective and

has a favorable toxicity profile in the treatment of mantle cell and low-grade

non-Hodgkin's lymphoma. J Clin Oncol 2005;23:3383-9.

30. Robinson KS, Williams ME, van der Jagt RH, et al. Phase II multicenter study of

bendamustine plus rituximab in patients with relapsed indolent B-cell and mantle cell

non-Hodgkin's lymphoma. J Clin Oncol 2008;26:4473-9.

31. Rummel M, Kaiser U, Balser C, et al. Bendamustine plus rituximab versus fludarabine

plus rituximab for patients with relapsed indolent and mantle-cell lymphomas: a

multicentre, randomised, open-label, non-inferiority phase 3 trial. Lancet Oncol

2016;17:57-66.

21
 ** This study reported the results of a phase III study to compare the efficacy and

safety of bendamustine or fludarabine in combination with rituximab in patients

with relapsed or refractory indolent B-NHL and MCL, demonstrating the

non-inferiority of BR against FR.

32. Visco C, Finotto S, Zambello R, et al. Combination of rituximab, bendamustine, and

cytarabine for patients with mantle-cell non-Hodgkin lymphoma ineligible for intensive

regimens or autologous transplantation. J Clin Oncol 2013;31:1442-9.

33. Rummel MJ, Niederle N, Maschmeyer G, et al. Bendamustine plus rituximab versus

CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell

lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial.

Lancet 2013;381:1203-10.

** This study reported the results of a phase III study to compare the efficacy and

safety of BR or R-CHOP in patients with untreated indolent B-NHL and MCL,

demonstrating the non-inferiority of BR against R-CHOP

34. Flinn IW, van der Jagt R, Kahl BS, et al. Randomized trial of bendamustine-rituximab

or R-CHOP/R-CVP in first-line treatment of indolent NHL or MCL: the BRIGHT study.

Blood 2014;123:2944-52.

35. Salles G, Seymour JF, Offner F, et al. Rituximab maintenance for 2 years in patients

with high tumour burden follicular lymphoma responding to rituximab plus

chemotherapy (PRIMA): a phase 3, randomised controlled trial. Lancet

2011;377:42-51.

36. Kluin-Nelemans HC, Hoster E, Hermine O, et al. Treatment of older patients with

mantle-cell lymphoma. N Engl J Med 2012;367:520-31.

37. Rummel M, Knauf W, Goerner M, et al. Two years rituximab maintenance vs.

observation after first-line treatment with bendamustine plus rituximab (B-R) in

22
 patients with mantle cell lymphoma: First results of a prospective, randomized,

multicenter phase II study (a subgroup study of StiL NHL7-2008 MAINTAIN trial).

Abstract 7503, ASCO annual meeting 2016

38. Weidmann E, Kim SZ, Rost A, et al. Bendamustine is effective in relapsed or refractory

aggressive non-Hodgkin's lymphoma. Ann Oncol 2002;13:1285-9.

39. Ohmachi K, Niitsu N, Uchida T, et al. Multicenter phase II study of bendamustine plus

rituximab in patients with relapsed or refractory diffuse large B-cell lymphoma. J Clin

Oncol 2013;31:2103-9.

40. Park SI, Grover NS, Olajide O, et al. A phase II trial of bendamustine in combination

with rituximab in older patients with previously untreated diffuse large B-cell lymphoma.

Br J Haematol 2016.: published online 22 July 2016, doi: 10.1111/bjh.14232

41. Garcia Munoz R, Izquierdo-Gil A, Munoz A, et al. Lymphocyte recovery is impaired in

patients with chronic lymphocytic leukemia and indolent non-Hodgkin lymphomas

treated with bendamustine plus rituximab. Ann Hematol 2014;93:1879-87.

42. Saito H, Maruyama D, Maeshima AM, et al. Prolonged lymphocytopenia after

bendamustine therapy in patients with relapsed or refractory indolent B-cell and

mantle cell lymphoma. Blood Cancer J 2015;5:e362.

43. Maddocks K, Christian B, Jaglowski S, et al. A phase 1/1b study of rituximab,

bendamustine, and ibrutinib in patients with untreated and relapsed/refractory

non-Hodgkin lymphoma. Blood 2015;125:242-8.

44. Albertsson-Lindblad A, Kolstad A, Laurell A, et al.

Lenalidomide-bendamustine-rituximab in untreated mantle cell lymphoma > 65 years,

the Nordic Lymphoma Group phase I+II trial NLG-MCL4. Blood 2016: published online

27 June 2016, pii: blood-2016-03-704023.

45. Zaja F, Ferrero S, Stelitano C, et al. Rituximab, lenalidomide, bendamustine second

23
 line therapy in mantle cell lymphoma: a phase II study of the Fondazione Italiana

Linfomi (FIL). Abstract 014. 13th International Conference on Malignant Lymphoma

ICML2015

46. Weide R, Feiten S, Friesenhahn V, et al. Retreatment with bendamustine-containing

regimens in patients with relapsed/refractory chronic lymphocytic leukemia and indolent

B-cell lymphomas achieves high response rates and some long lasting remissions. Leuk

Lymphoma 2013;54:1640-6.

Figure 1: Chemical structure of bendamustine

Bendamustine is composed of three elements, a mechlorethamine (nitrogen

mustard) group, a benzimidazole ring, and a butyric acid side chain (carboxylic acid).

Bendamustine

ClH2C

Butyric acid side chain

N N
ClH2C COOH
N

Mechlorethamine CH3 Benzimidazole ring

NH2
Cl N
N

O O N N
F
N P
Cl HO
N O Purine analog
H HO
(Fludarabine)
Alkylating agent
(Cyclophosphamide) OH

24
 Table1. Clinical trials of bendamustine in patients with B-NHL

Study Histology Number of patients Treatment ORR %CR Median PFS

(%) (%) (Months)

Friedberg R/R indolent B-NHL and 76 B: 120 mg/m2 (day1, 2) 77 34 7.1

(phase II)27 transformed B-NHL (6.0 - 8.9)

Khal R/R indolent B-NHL 100 B: 120 mg/m2 (day1, 2) 75 17 9.3

28
(phase II) (8.1 - 11.9)

Rummel R/R indolent B-NHL and MCL 63 B: 90 mg/m2 (day1, 2) 90 60 24

29 2
(phase II) R: 375 mg/m (day1) (5 - ≥44)

Robinson Relapsed indolent 67 B: 90 mg/m2 (day1, 2) 92 55 23

30 2
(phase II) B-NHL and MCL R: 375 mg/m (day1) (20 - 26)

Rummel R/R indolent B-NHL and MCL 114 B: 90 mg/m2 (day1, 2) 82 40 34.2
(phase III)31 R: 375 mg/m2 (day1) (23.5 - 52.7)
105 F: 25 mg/m2 (day1 - 3) 51 17 11.7
2
R: 375 mg/m (day1) (8.0 - 16.1)
Visco Untreated or R/R MCL 40 B: 70 mg/m2 (day1, 2) 90 83 NR
32
(phase II) AraC: 800mg/m2 (day3)
R: 375 mg/m2 (day1)
Rummel Untreated indolent B-NHL and 261 B: 90 mg/m2 (day1, 2) 93 40 69.5
(phase III)33 MCL R: 375 mg/m2 (day1) (26.1 - NR)

253 C: 750 mg/m2 (day1) 91 30 31.2

2
H: 50 mg/m (day1) (15.2 - 65.7)
2
O: 1.4 mg/m (day1)
P: 100mg/day (day1 - 5)
R: 375 mg/m2 (day1)
Flinn Untreated indolent B-NHL and 213 B: 90 mg/m2 (day1, 2) 97 31 Not reported
(phase III)34 MCL R: 375 mg/m2 (day1)
206 C: 750 mg/m2 (day1) 91 25 Not reported

25
 H: 50 mg/m2 (day1)
O: 1.4 mg/m2 (day1)
P: 100mg/day (day1 - 5)
R: 375 mg/m2 (day1)
Weidmann R/R aggressive 18 B: 120 mg/m2 (day1, 2) 44 17 Not reported
38
(phase II) NHL
Ohmachi R/R DLBCL 63 B: 120 mg/m2 (day2, 3) 63 37 6.7
39 2
(phase II) R: 375 mg/m (day1) (3.6 - 13.7)
2
Park Untreated DLBCL 23 B: 120 mg/m (day1, 2) 78 52 5.4
(phase II)40 (older patients) R: 375 mg/m2 (day1) (3.8 - 10.0)

B-NHL, B cell non-Hodgkin lymphoma; MCL, mantle cell lymphoma; DLBCL, diffuse large B-cell lymphoma; R/R, relapsed or refractory;

ORR, overall response rate; %CR, complete remission rate; PFS, progression free survival; NR, not reached;

B, bendamustine; R, rituximab; F, fludarabine; C, cyclophosphamide; H, doxorubicin; O, vincristine; P, predonisone

26